A test of the loose-equilibrium concept with long-lived organisms: Evaluating temporal change in freshwater mussel assemblages.

The loose-equilibrium concept (LEC) predicts that ecological assemblages change transiently but return towards an earlier or average structure. The LEC framework can help determine whether assemblages vary within expected ranges or are permanently altered following environmental change. Long-lived, slow-growing animals typically respond slowly to environmental change, and their assemblage dynamics may respond over decades, which transcends most ecological studies. Unionid mussels are valuable for studying dynamics of long-lived animals because they can live >50 years and occur in dense, species-rich assemblages (mussel beds). Mussel beds can persist for decades, but disturbance can affect species differently, resulting in variable trajectories according to differences in species composition within and among rivers. We used long-term data sets (10-40 years) from seven rivers in the eastern United States to evaluate the magnitude, pace and directionality of mussel assemblage change within the context of the LEC. Site trajectories varied within and among streams and showed patterns consistent with either the LEC or directional change. In streams that conformed to the LEC, rank abundance of dominant species remained stable over time, but directional change in other streams was driven by changes in the rank abundance and composition of dominant species. Characteristics of mussel assemblage change varied widely, ranging from those conforming to the LEC to those showing strong directional change. Conservation approaches that attempt to maintain or create a desired assemblage condition should acknowledge this wide range of possible assemblage trajectories and that the environmental factors that influence those changes remain poorly understood.

Glacial vicariance and secondary contact shape demographic histories in a freshwater mussel species complex.

Characterizing the mechanisms influencing the distribution of genetic variation in aquatic species can be difficult due to the dynamic nature of hydrological landscapes. In North America's Central Highlands, a complex history of glacial dynamics, long-term isolation, and secondary contact have shaped genetic variation in aquatic species. Although the effects of glacial history have been demonstrated in many taxa, responses are often lineage- or species-specific and driven by organismal ecology. In this study, we reconstruct the evolutionary history of a freshwater mussel species complex using a suite of mitochondrial and nuclear loci to resolve taxonomic and demographic uncertainties. Our findings do not support Pleurobema rubrum as a valid species, which is proposed for listing as threatened under the U.S. Endangered Species Act. We synonymize P. rubrum under Pleurobema sintoxia-a common and widespread species found throughout the Mississippi River Basin. Further investigation of patterns of genetic variation in P. sintoxia identified a complex demographic history, including ancestral vicariance and secondary contact, within the Eastern Highlands. We hypothesize these patterns were shaped by ancestral vicariance driven by the formation of Lake Green and subsequent secondary contact after the last glacial maximum. Our inference aligns with demographic histories observed in other aquatic taxa in the region and mirrors patterns of genetic variation of a freshwater fish species (Erimystax dissimilis) confirmed to serve as a parasitic larval host for P. sintoxia. Our findings directly link species ecology to observed patterns of genetic variation and may have significant implications for future conservation and recovery actions of freshwater mussels.

His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy vs Biventricular Pacing: HOT-CRT Clinical Trial.

BACKGROUND: His-Purkinje conduction system pacing (HPCSP) using His bundle pacing (HBP) or left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing (BVP) in patients requiring cardiac resynchronization therapy (CRT). OBJECTIVES: The aim of the study was to compare the feasibility and clinical efficacy of HOT-CRT (His-Purkinje conduction system pacing Optimized Trial of Cardiac Resynchronization Therapy) with BVP in patients with heart failure, reduced ejection fraction, and indication for CRT. METHODS: This was a prospective, randomized, controlled trial of HOT-CRT and BVP in patients with LVEF <50% and indications for CRT. If HPCSP resulted in incomplete electrical resynchronization, a coronary sinus (CS) lead was added. The primary outcome was the change in left ventricular ejection fraction (LVEF) at 6 months. The primary safety endpoint was freedom from major complications. RESULTS: A total of 100 patients (female 31%, aged 70 ± 12 years, LVEF 31.5% ± 9.0%) were randomized. HOT-CRT was successful in 48 of 50 (96%) and BVP-CRT in 41 of 50 (82%) patients (P = 0.03). QRS duration significantly decreased from 164 ± 26 ms to 137 ± 20 ms with HOT-CRT and 166 ± 28 ms to 141 ± 19 ms with BVP. Fluoroscopy results (18.8 ± 12.4 min vs 23.8 ± 12.4 min, P = 0.05) and procedure duration (119 ± 42 min vs 114 ± 36 min, P = 0.5) were similar. The primary outcome of change in LVEF at 6 months was greater in HOT-CRT than in BVP (12.4% ± 7.3% vs 8.0% ± 10.1%, P = 0.02). The primary safety endpoint was similar (98% vs 94%, P = 0.62). Echocardiographic response of improvement in LVEF >5% occurred in 80% vs 61% (P = 0.06). Complications occurred in 3 (6%) in HOT-CRT vs 10 (20%) in BVP (P = 0.03). CONCLUSIONS: HPCSP-guided CRT resulted in greater change in LVEF compared with BVP. Randomized clinical trials with long-term follow-up are necessary. (His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy [HOT-CRT]; NCT04561778).

Excessive use of electronic devices among children and adolescents is associated with musculoskeletal symptoms, visual symptoms, psychosocial health, and quality of life: a cross-sectional study.

Objective: Electronic devices have become an indispensable part of our daily lives. The frequency and duration of device use in children and adolescents have increased drastically over the years and the study of its negative musculoskeletal, visual and psychosocial health impacts is necessary. Materials and methods: This cross-sectional study aimed to evaluate the associations between electronic device use and the prevalence and severity of musculoskeletal symptoms, visual symptoms, psychosocial health, and quality of life in children and adolescents studying at primary and secondary schools. Data were collected through confidential online and paper-and-pencil questionnaires. Primary 4-5 and Secondary 1-4 students were recruited from 3 schools in Hong Kong. Demographics, frequency and duration of electronic device use, frequencies of musculoskeletal symptoms, visual symptoms, psychosocial health, and quality of life outcomes were measured. Results: 1,058 children and adolescents aged 9-17 years participated. Sixty-one percent and 78% of all students spent more than 2 h per day using electronic devices during school days and weekend/holidays, respectively. Extended electronic device use was associated with increased prevalence and severity of musculoskeletal symptoms (ρ's = 0.28-0.33, P's < 0.001), visual symptoms (ρ's = 0.33-0.35, P's < 0.001), and poorer device use-related psychosocial health (ρ's = 0.38-0.47, P's < 0.001). Secondary school students reported greater device use and severity of symptoms than primary school students. Conclusion: Excessive electronic device use was associated with increased prevalence and severity of physical and psychosocial symptoms, and such use is more prevalent in adolescents when compared to the children. The findings have important health implications for children and adolescents, suggesting that early intervention is needed to reduce the risk of developing device use-related disorders.

Histological evaluations of organ tissues reveal sublethal effects in a freshwater mussel (Villosa iris) exposed to chloride and potassium concentrations below benchmark estimates.

Salinization of freshwater ecosystems due to anthropogenic sources will increasingly impact biodiversity. An example of point-source industrial salinization has occurred from historical activities at a U.S. Environmental Protection Agency Superfund Site near Saltville, Virginia USA and its associated chemical waste ponds adjacent to the North Fork Holston River. These point source discharges are documented contributors to mussel declines, partially due to high concentrations of chloride (Cl-, ≤ 26,000 mg Cl-/L) and potassium (K+, ≤ 97 mg K+/L). During a chronic 61-day laboratory study, Rainbow mussels, Villosa iris, were exposed to concentrations of Cl- (0, 416, 831, and 1,663 mg/L) and K+ (0, 4, 8, and 17 mg/L) to determine effects on survival and organ tissues. All test mussels died by day-2 in the 1,663 mg Cl-/L exposure, and 50% of mussels died by day-13 in the 17 mg K+/L concentration. Significantly greater abundances of tissue abnormalities were observed in digestive glands and kidneys with exposures to the 4 and 8 mg/L concentrations of K+ versus the control, and significantly greater abundances of lesions in kidneys were observed in the 416 and 831 mg Cl-/L concentrations compared to the control. The sublethal effects to digestive glands and kidneys were below reported effect (EC50, 20, 10 and LOEC) concentrations. Significant histological differences between control and baseline (day-0 sample) mussels were observed, suggesting the need for further study on the effects of captivity during longer-term laboratory experiments.

Description of the mantle lure and novel mimicry of the endangered Cumberlandian Combshell (Epioblasma brevidens) in the Clinch River, eastern United States.

The Cumberlandian Combshell (Epioblasma brevidens) is an endangered freshwater mussel endemic to the Tennessee and Cumberland River drainages, major tributaries of the Ohio River of the eastern United States. We conducted mask and snorkel surveys in May and June of 2021 and 2022 to locate, observe, photograph, and video female E. brevidens to document their unique mantle lures at sites in the Clinch River in Tennessee and Virginia. The mantle lure is morphologically specialized mantle tissue that mimics prey items of the host fish. The mantle lure of E. brevidens appears to mimic four distinct characteristics of the reproductive anatomy of the underside (ventral) of a gravid female crayfish, to include: (1) the external apertures of the oviducts located on the base of the third pair of walking legs, (2) crayfish larvae still encased in the egg membrane, (3) pleopods or claws, and (4) postembryonic eggs. Surprisingly, we observed males of E. brevidens displaying mantle lures that were anatomically complex and closely resembled the female mantle lure. The male lure similarly mimics oviducts, eggs, and pleopods but is diminutive (2-3 mm smaller in length or diameter) to those same structures in females. We describe for the first time the mantle lure morphology and mimicry of E. brevidens, showing its close resemblance to the reproductive anatomy of a gravid female crayfish, and a novel form of mimicry in males. To our knowledge, mantle lure displays in males have not been previously documented in freshwater mussels.

Phylogenetic assessment of endangered and look-alike Pigtoe species in a freshwater mussel diversity hotspot.

The Green River in Kentucky in the eastern United States is a freshwater mussel biodiversity hotspot, with 71 known species. Among them, the endangered Pleurobema plenum coexists with other morphologically similar species in the genera Fusconaia and Pleurobema, known colloquially as "pigtoes." Identification of species in these genera is challenging even for mussel experts familiar with them. In our study, the correct identification of these species by experts ranged from 57% to 83%. We delineated taxonomic boundaries among seven species and tested for cryptic biodiversity among these look-alike mussels utilizing mitochondrial and nuclear DNA sequence variation. Phylogenetic analysis of combined (1215 bp) mitochondrial DNA cytochrome oxidase I (COI) and NADH dehydrogenase 1 (ND1) genes showed five well-diverged groups that included F. flava, F. subrotunda, P. cordatum, and P. plenum as distinct clades, with P. sintoxia and P. rubrum grouped into a single clade. While our mitochondrial DNA analyses did not distinguish P. sintoxia and P. rubrum as phylogenetically distinct species, the typical shell forms of these two nominal taxa are very distinct. Further phylogenetic analysis using nuclear ribosomal transcribed spacer region subunit I (ITS1) DNA sequences also showed that P. sintoxia and P. rubrum were not distinct lineages. No cryptic species were detected in the Fusconaia and Pleurobema samples analyzed from the Green River. The highest haplotype diversity (h), average number of nucleotide differences (k), and nucleotide diversity (π) were observed for F. subrotunda at both the COI (h = 0.896, k = 3.805, π = 0.00808) and ND1 (h = 0.984, k = 6.595, π = 0.00886) markers, with similarly high genetic diversity in the other taxa. Our results give managers confidence that cryptic taxa do not occur within or among these morphologically similar species in the Green River, and populations appear genetically diverse, indicative of large and healthy populations.

Severity of slouched posture during smartphone use is associated with the musculoskeletal discomfort, daily usage, and school year among adolescents.

Real-time measurement of the craniovertebral, thoracic kyphosis, and lumbar lordosis angles during natural and smartphone usage postures in sitting were analysed in a cohort of 560 adolescents using independent t-tests and Spearman's correlations between their reported musculoskeletal symptoms, daily device use and school year. Students with musculoskeletal symptoms (mean difference: 4.1-9.4°, p < .001) and in secondary schools (mean difference: 13.6-29.4°, p < .001) had a greater forward-head posture quantified by craniovertebral angle in both postures. Loss of lumbar lordosis was found in students spending ≥2 h/day on electronic devices (mean difference: 3.2°, p = .029) and those with musculoskeletal symptoms (mean difference: 5.4°, p = .001). Secondary school students exhibited a greater thoracic kyphosis when using smartphones (mean difference: 3.3°, p = .003). Findings suggest the urgent need for early and proactive intervention targeted to minimise the risk of developing musculoskeletal disorders related to intense device use for young adolescents.Practitioner Summary: Adolescents: (1) in higher school year had increased forward-head posture (FHP) and thoracic kyphosis; (2) with musculoskeletal symptoms had increased FHP and loss of lumbar lordosis, and; (3) with extended device use had a loss of lumbar lordosis. Early intervention targeting young adolescents promoting optimal posture and habit of device use is warranted.

Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors.

BACKGROUND: Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. METHODS: The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]). RESULTS: A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001). CONCLUSIONS: The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.

Conduction system pacing versus conventional pacing in patients undergoing atrioventricular node ablation: Nonrandomized, on-treatment comparison.

Background: Atrioventricular node ablation (AVNA) with right ventricular or biventricular pacing (conventional pacing; CP) is an effective therapy for patients with refractory atrial fibrillation (AF). Conduction system pacing (CSP) using His bundle pacing or left bundle branch area pacing preserves ventricular synchrony. Objective: The aim of our study is to compare the clinical outcomes between CP and CSP in patients undergoing AVNA. Methods: Patients undergoing AVNA at Geisinger Health System between January 2015 and October 2020 were included in this retrospective observational study. CP or CSP was performed at the operators' discretion. Procedural, pacing parameters, and echocardiographic data were assessed. Primary outcome was the combined endpoint of time to death or heart failure hospitalization (HFH) and was analyzed using Cox proportional hazards. Secondary outcomes were individual outcomes of time to death and HFH. Results: AVNA was performed in 223 patients (CSP, 110; CP, 113). Age was 75 ± 10 years, male 52%, hypertension 67%, diabetes 25%, coronary disease 40%, and left ventricular ejection fraction (LVEF) 43% ± 15%. QRS duration increased from 103 ± 30 ms to 124 ± 20 ms (P < .01) in CSP and 119 ± 32 ms to 162 ± 24 ms in CP (P < .001). During a mean follow-up of 27 ± 19 months, LVEF significantly increased from 46.5% ± 14.2% to 51.9% ± 11.2% (P = .02) in CSP and 36.4% ± 16.1% to 39.5% ± 16% (P = .04) in CP. The primary combined endpoint of time to death or HFH was significantly reduced in CSP compared to CP (48% vs 62%; hazard ratio 0.61, 95% confidence interval 0.42-0.89, P < .01). There was no reduction in the individual secondary outcomes of time to death and HFH in the CSP group compared to CP. Conclusion: CSP is a safe and effective option for pacing in patients with AF undergoing AVNA in high-volume centers.

Clinical outcomes of conduction system pacing compared to biventricular pacing in patients requiring cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) with biventricular pacing (BVP) is well-established therapy in patients with reduced left ventricular ejection fraction (LVEF) and bundle branch block or indication for pacing. Conduction system pacing (CSP) using His-bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has been shown to be a safe and more physiological alternative to BVP. OBJECTIVE: The purpose of this study was to compare the clinical outcomes between CSP and BVP among patients undergoing CRT. METHODS: This observational study included consecutive patients with LVEF ≤35% and class I or II indications for CRT who underwent successful BVP or CSP at 2 major health care systems. The primary outcome was the composite endpoint of time to death or heart failure hospitalization (HFH). Secondary outcomes included subgroup analysis in left bundle branch block as well as individual endpoints of death and HFH. RESULTS: A total of 477 patients (32% female) met inclusion criteria (BVP 219; CSP 258 [HBP 87, LBBAP 171]). Mean age was 72 ± 12 years, and mean LVEF was 26% ± 6%. Comorbidities included hypertension 70%, diabetes mellitus 45%, and coronary artery disease 52%. Paced QRS duration in CSP was significantly narrower than BVP (133 ± 21 ms vs 153 ± 24 ms; P <.001). LVEF improved in both groups during mean follow-up of 27 ± 12 months and was greater after CSP compared to BVP (39.7% ± 13% vs 33.1% ± 12%; P <.001). Primary outcome of death or HFH was significantly lower with CSP vs BVP (28.3% vs 38.4%; hazard ratio 1.52; 95% confidence interval 1.082-2.087; P = .013). CONCLUSION: CSP improved clinical outcomes compared to BVP in this large cohort of patients with indications for CRT.

Combined effects of copper, nickel, and zinc on growth of a freshwater mussel (Villosa iris) in an environmentally relevant context.

Trace metals rarely contaminate freshwaters independently, hence regulatory limits based on single-metal toxicity may be underprotective of aquatic life. This could be especially the case for rare and sensitive fauna like freshwater mussels, such as those suppressed in the Clinch and Powell Rivers in eastern USA where trace metals are long-term contaminants but at concentrations below regulatory limits. We hypothesized metal mixtures may be exerting combined effects on mussels, resulting in greater toxicity than would be predicted based on single-metal exposures. To test that hypothesis, we conducted two experiments exposing juvenile rainbow mussels (Villosa iris) for 42 days to dissolved copper, nickel, and zinc, individually and in three-metal mixtures, in an environmentally-relevant context of water with chemistry (hardness 155 mg/L as CaCO3, dissolved organic carbon 1.7-2.3 mg/L, pH 8.4) similar to that of the Clinch River, which receives alkaline mine drainage. We used a toxic unit approach, selecting test concentrations based on literature values for the lower of 28-day survival or growth (length) effect concentrations for Villosa iris or Lampsilis siliquoidea (fatmucket). Our first experiment confirmed survival and growth effects when acute and chronic water quality criteria, respectively, are approached and/or exceeded. Our second experiment, at lower concentrations, showed no effects on survival but combined effects on growth were evident: a mixture of Cu, Ni, and Zn (7.2 ± 1.2, 65.3 ± 6.1, 183 ± 32 µg/L, respectively) inhibited growth (dry weight) by 95% versus 73%, 74%, and 83% inhibition for single-metal exposures to Cu, Ni, and Zn of similar concentration (8.0 ± 1.1, 63.5 ± 4.8, 193 ± 31 µg/L, respectively). Furthermore, a mixture of Cu, Ni, and Zn with individual concentrations 21%, 29%, and 37% of their water quality criteria (3.4 ± 1.2, 21.8 ± 1.8, and 62.1 ± 8.4 µg/L, respectively) inhibited growth (dry weight) by 61% relative to controls. Our observation of combined effects suggests that regulatory limits based on single-metal toxicity may be underprotective of freshwater mussels when multiple metals are present.

Cognitive Recovery by Decade in Healthy 40- to 80-Year-Old Volunteers After Anesthesia Without Surgery.

BACKGROUND: Postoperative delirium and postoperative cognitive dysfunction are the most common complications for older surgical patients. General anesthesia may contribute to the development of these conditions, but there are little data on the association of age with cognitive recovery from anesthesia in the absence of surgery or underlying medical condition. METHODS: We performed a single-center cohort study of healthy adult volunteers 40 to 80 years old (N = 71, mean age 58.5 years, and 44% women) with no underlying cognitive dysfunction. Volunteers underwent cognitive testing before and at multiple time points after 2 hours of general anesthesia consisting of propofol induction and sevoflurane maintenance, akin to a general anesthetic for a surgical procedure, although no procedure was performed. The primary outcome was time to recovery to cognitive baseline on the Postoperative Quality of Recovery Scale (PQRS) within 30 days of anesthesia. Secondary cognitive outcomes were time to recovery on in-depth neuropsychological batteries, including the National Institutes of Health Toolbox and well-validated paper-and-pencil tests. The primary hypothesis is that time to recovery of cognitive function after general anesthesia increases across decades from 40 to 80 years of age. We examined this with discrete-time logit regression (for the primary outcome) and linear mixed models for interactions of age decade with time postanesthesia (for secondary outcomes). RESULTS: There was no association between age group and recovery to baseline on the PQRS; 36 of 69 (52%) recovered within 60-minute postanesthesia and 63 of 69 (91%) by day 1. Hazard ratios (95% confidence interval) for each decade compared to 40- to 49-year olds were: 50 to 59 years, 1.41 (0.50-4.03); 60 to 69 years, 1.03 (0.35-3.00); and 70 to 80 years, 0.69 (0.25-1.88). There were no significant differences between older decades relative to the 40- to 49-year reference decade in recovery to baseline on secondary cognitive measures. CONCLUSIONS: Recovery of cognitive function to baseline was rapid and did not differ between age decades of participants, although the number in each decade was small. These results suggest that anesthesia alone may not be associated with cognitive recovery in healthy adults of any age decade.

Lateralisation of subcortical functional connectivity during and after general anaesthesia.

BACKGROUND: Arousal and awareness are two important components of consciousness states. Functional neuroimaging has furthered our understanding of cortical and thalamocortical mechanisms of awareness. Investigating the relationship between subcortical functional connectivity and arousal has been challenging owing to the relatively small size of brainstem structures and thalamic nuclei, and their depth in the brain. METHODS: Resting state functional MRI scans of 72 healthy volunteers were acquired before, during, 1 h after, and 1 day after sevoflurane general anaesthesia. Functional connectivity of subcortical regions of interest vs whole brain and homotopic functional connectivity for assessment of left-right symmetry analyses of both cortical and subcortical regions of interest were performed. Both analyses used high resolution atlases generated from deep brain stimulation applications. RESULTS: Functional connectivity in subcortical loci within the thalamus and of the ascending reticular activating system was sharply restricted under anaesthesia, featuring a general lateralisation of connectivity. Similarly, left-right homology was sharply reduced under anaesthesia. Subcortical bilateral functional connectivity was not fully restored after emergence from anaesthesia, although greater restoration was seen between ascending reticular activating system loci and specific thalamic nuclei thought to be involved in promoting and maintaining arousal. Functional connectivity was fully restored to baseline by the following day. CONCLUSIONS: Functional connectivity in the subcortex is sharply restricted and lateralised under general anaesthesia. This restriction may play a part in loss and return of consciousness. CLINICAL TRIAL REGISTRATION: NCT02275026.

Clinical outcomes of left bundle branch area pacing compared to right ventricular pacing: Results from the Geisinger-Rush Conduction System Pacing Registry.

BACKGROUND: Left bundle branch area pacing (LBBAP) has been shown to be a feasible option for patients requiring ventricular pacing. OBJECTIVE: The purpose of this study was to compare clinical outcomes between LBBAP and RVP among patients undergoing pacemaker implantation METHODS: This observational registry included patients who underwent pacemaker implantations with LBBAP or RVP for bradycardia indications between April 2018 and October 2020. The primary composite outcome included all-cause mortality, heart failure hospitalization (HFH), or upgrade to biventricular pacing. Secondary outcomes included the composite endpoint among patients with a prespecified burden of ventricular pacing and individual outcomes. RESULTS: A total of 703 patients met inclusion criteria (321 LBBAP and 382 RVP). QRS duration during LBBAP was similar to baseline (121 ± 23 ms vs 117 ± 30 ms; P = .302) and was narrower compared to RVP (121 ± 23 ms vs 156 ± 27 ms; P <.001). The primary composite outcome was significantly lower with LBBAP (10.0%) compared to RVP (23.3%) (hazard ratio [HR] 0.46; 95%T confidence interval [CI] 0.306-0.695; P <.001). Among patients with ventricular pacing burden >20%, LBBAP was associated with significant reduction in the primary outcome compared to RVP (8.4% vs 26.1%; HR 0.32; 95% CI 0.187-0.540; P <.001). LBBAP was also associated with significant reduction in mortality (7.8% vs 15%; HR 0.59; P = .03) and HFH (3.7% vs 10.5%; HR 0.38; P = .004). CONCLUSION: LBBAP resulted in improved clinical outcomes compared to RVP. Higher burden of ventricular pacing (>20%) was the primary driver of these outcome differences.

Genetic and morphological characterization of the freshwater mussel clubshell species complex (Pleurobema clava and Pleurobema oviforme) to inform conservation planning.

The shell morphologies of the freshwater mussel species Pleurobema clava (federally endangered) and Pleurobema oviforme (species of concern) are similar, causing considerable taxonomic confusion between the two species over the last 100 years. While P. clava was historically widespread throughout the Ohio River basin and tributaries to the lower Laurentian Great Lakes, P. oviforme was confined to the Tennessee and the upper Cumberland River basins. We used two mitochondrial DNA (mtDNA) genes, 13 novel nuclear DNA microsatellite markers, and shell morphometrics to help resolve this taxonomic confusion. Evidence for a single species was apparent in phylogenetic analyses of each mtDNA gene, revealing monophyletic relationships with minimal differentiation and shared haplotypes. Analyses of microsatellites showed significant genetic structuring, with four main genetic clusters detected, respectively, in the upper Ohio River basin, the lower Ohio River and Great Lakes, and upper Tennessee River basin, and a fourth genetic cluster, which included geographically intermediate populations in the Ohio and Tennessee river basins. While principal components analysis (PCA) of morphometric variables (i.e., length, height, width, and weight) showed significant differences in shell shape, only 3% of the variance in shell shape was explained by nominal species. Using Linear Discriminant and Random Forest (RF) analyses, correct classification rates for the two species' shell forms were 65.5% and 83.2%, respectively. Random Forest classification rates for some populations were higher; for example, for North Fork Holston (HOLS), it was >90%. While nuclear DNA and shell morphology indicate that the HOLS population is strongly differentiated, perhaps indicative of cryptic biodiversity, we consider the presence of a single widespread species the most likely biological scenario for many of the investigated populations based on our mtDNA dataset. However, additional sampling of P. oviforme populations at nuclear loci is needed to corroborate this finding.

Palliative Care Consultation for Hospitalized Patients with Primary and Secondary Brain Tumors at a Single Academic Center.

Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p < 0.001); sickest at baseline (mean Elixhauser comorbidity index 3.76; trigger: 3.49; usual care: 1.84; p < 0.001); and had highest in-hospital death [34 (13.8%), trigger: 10 (7.1%), usual care: 7 (0.5%); p < 0.001] and hospice discharge [54 (22.0%), trigger: 18 (12.9%), usual care: 14 (1.1%); p < 0.001]. Conclusions: Trigger criteria may promote earlier palliative care referral, yet criteria tailored for neuro-oncology are undeveloped.

Understanding the influence of multiple pollutant stressors on the decline of freshwater mussels in a biodiversity hotspot.

The Clinch River watershed of the upper Tennessee River Basin of Virginia and Tennessee, USA supports one of North America's greatest concentrations of freshwater biodiversity, including 46 extant species of native freshwater mussels (Order Unionida), 20 of which are protected as federally endangered. Despite the global biological significance of the Clinch River, mussel populations are declining in some reaches, both in species richness and abundance. The aim of this study was to evaluate the exposure of adult resident mussels to a suite of inorganic and organic contaminant stressors in distinct sections of the Clinch River that encompassed a range of mussel abundance and health. To provide insight into the potential role of pollutants in the decline of mussels, including within a previously documented "zone of mussel decline", the mainstem Clinch River (8 sites) and its tributaries (4 sites) were examined over two consecutive years. We quantified and related metals and organic contaminant concentrations in mussels to their associated habitat compartments (bed sediment, suspended particulate sediment, pore water, and surface water). We found that concentrations of organic contaminants in resident mussels, particularly the suite of 42 polycyclic aromatic hydrocarbons (PAHs) analyzed, were related to PAH concentrations in all four habitat (media) compartments. Further, PAH concentrations in mussel tissue (range 37.8-978.1 ng/g dry weight in 2012 and 194.3-1073.7 ng/g dry weight in 2013) were negatively related to the spatial pattern in mussel densities (rs = -0.64, p ≤ 0.05 in 2012 and rs = -0.83, p ≤ 0.05 in 2013) within the river, and were highest in the "zone of mussel decline". In contrast, the suite of 22 metals analyzed in resident mussels were largely unrelated to the spatial pattern of variation of metals in the four habitat compartments except for Manganese (Mn; range 3630.5-23,749.2 µg/g dry weight in 2012 and 1540.4-12,605.8 µg/g dry weight in 2013) in surface water (rs = 0.58, p < 0.1) and pore water (rs = 0.76, p ≤ 0.05). This study revealed that PAHs and Mn are important pollutant stressors to mussels in the Clinch River and that they are largely being delivered through the Guest River tributary watershed. Accordingly, future conservation and management efforts would benefit by identifying, and ideally mitigating, the sources of PAHs, Mn, and other current or legacy mining-associated pollutants to the mainstem river and its tributaries.