Decreased bone mass in adolescents with bone fragility fracture but not in young children: a case-control study.

Background: The incidence of distal forearm fracture due to minimal/moderate trauma shows a bimodal distribution for age at event, with one peak occurring during early adolescence, in both boys and girls and the other one in postmenopausal females. The aim of this study was, therefore, to document whether the relationship between bone mineral density and fracture is different in young children compared with adolescents. Methods: A matched-pair, case-control study has been conducted to evaluate bone mineral density in 469 young children and 387 adolescents of both sexes, with/without fracture due to minimal/moderate trauma with assurance that the compared groups were equally susceptible to the outcome event. All fractures were radiographically confirmed. The study utilized bone mineral areal density of the total body, spine, hips, and forearm; volumetric bone mineral density of the forearm; and metacarpal radiogrammetry measurements. The study controlled for skeletal development, bone geometry, body composition, hand grip strength, calcium intake, and vitamin D status. Results: Adolescents with distal forearm fracture have reduced bone mineral density at multiple skeletal regions of interest. This was documented by the bone mineral areal density measurements at multiple skeletal sites (p < 0.001), volumetric bone mineral density measurements of the forearm (p < 0.0001), and metacarpal radiogrammetry (p < 0.001). Adolescent females with fracture had reduced cross-sectional areas of the radius and metacarpals. The bone status of young female and male children with fracture was no different to its controls. Increased body fatness was more prevalent among fracture cases than in controls. Around 72% of young female and male children with fracture had serum 25-hydroxyvitamin D levels below the threshold of 31 ng/ml, compared with only 42% of female controls and to 51% of male controls. Conclusions: Adolescents with bone fragility fracture had reduced bone mineral density at multiple skeletal regions of interest, whereas this was not the case with younger children. The results of the study may have implications for the prevention of bone fragility in this segment of the pediatric population.

Oldest evidence of abundant C4 grasses and habitat heterogeneity in eastern Africa.

The assembly of Africa's iconic C4 grassland ecosystems is central to evolutionary interpretations of many mammal lineages, including hominins. C4 grasses are thought to have become ecologically dominant in Africa only after 10 million years ago (Ma). However, paleobotanical records older than 10 Ma are sparse, limiting assessment of the timing and nature of C4 biomass expansion. This study uses a multiproxy design to document vegetation structure from nine Early Miocene mammal site complexes across eastern Africa. Results demonstrate that between ~21 and 16 Ma, C4 grasses were locally abundant, contributing to heterogeneous habitats ranging from forests to wooded grasslands. These data push back the oldest evidence of C4 grass-dominated habitats in Africa-and globally-by more than 10 million years, calling for revised paleoecological interpretations of mammalian evolution.

A tranquil virtual reality experience to reduce subjective stress among COVID-19 frontline healthcare workers.

OBJECTIVE: The novel coronavirus-19 (COVID-19) has taken an immense physical, social, and emotional toll on frontline healthcare workers. Research has documented higher levels of anxiety, depression, and burnout among healthcare workers during the pandemic. Thus, creative interventions are needed now more than ever to provide brief, accessible support to frontline workers. Virtual reality is a rapidly growing technology with potential psychological applications. In this study, we piloted a three-minute Tranquil Cinematic-VR simulation of a nature scene to lower subjective stress among frontline healthcare workers in COVID-19 treatment units. We chose to film a nature scene because of the extensive empirical literature documenting the benefits of nature exposure and health. METHODS: A convenience sample of frontline healthcare workers, including direct care providers, indirect care providers, and support or administrative services, were recruited from three COVID-19 units located in the United States. Inclusion criteria for participation included adults aged 18 years and older who could read and speak in English and were currently employed by the healthcare system. Participants viewed a 360-degree video capture of a lush, green nature preserve in an Oculus Go or Pico G2 4K head-mounted display. Prior to viewing the simulation, participants completed a brief demographic questionnaire and the visual analogue scale to rate their subjective stress on a 10-point scale, with 1 = 'Not at all stressed' to 10 = 'Extremely stressed.' We conducted paired t-tests to examine pre- and post-simulation changes in subjective stress as well as Kruskal-Wallis tests and Mann-Whitney U tests to examine differences by demographic variables. All analyses were conducted in SPSS statistical software version 28.0. We defined statistical significance as a p-value less than .05. RESULTS: A total of 102 individuals consented to participate in the study. Eighty-four (82.4%) participants reported providing direct patient care, 73 (71.6%) identified as women, 49 (48.0%) were between the ages of 25-34 years old, and 35 (34.3%) had prior experience with VR. The pre-simulation mean stress score was 5.5±2.2, with a range of 1 to 10. Thirty-three (32.4%) participants met the 6.8 cutoff for high stress pre-simulation. Pre-simulation stress scores did not differ by any demographic variables. Post-simulation, we observed a significant reduction in subjective stress scores from pre- to post-simulation (mean change = -2.2±1.7, t = 12.749, p < .001), with a Cohen's d of 1.08, indicating a very large effect. Further, only four (3.9%) participants met the cutoff for high stress after the simulation. Post-simulations scores did not differ by provider type, age range, gender, or prior experience with virtual reality. CONCLUSIONS: Findings from this pilot study suggest that the application of this Tranquil Cinematic-VR simulation was effective in reducing subjective stress among frontline healthcare workers in the short-term. More research is needed to compare the Tranquil Cinematic-VR simulation to a control condition and assess subjective and objective measures of stress over time.

The Interests of Family Medicine Residents in Future Faculty Positions Across the Senior Year.

BACKGROUND AND OBJECTIVES: The shortage of residency faculty in the pipeline is a growing concern to meet future workforce needs, though there is little research on attracting residents to be future faculty or what factors would influence their interest in this role. The objectives of this study were: (1) To assess the interest of third year residents (R3s) in faculty positions, and the various factors that might positively or negatively affect this decision; (2) to compare whether this changes across the R3 year; and (3) to compare between chief residents and other R3s. METHODS: Longitudinal survey at two points in time for each of three consecutive cohorts of R3s (2016-2018) from a regional network of family medicine residency programs. RESULTS: Among the final sample of R3s (176/545, 32% response), nearly half were interested in a residency faculty role. Strong positive influences on interest include the teaching role, advising/mentoring role, range of practice scope, and ability to perform procedures; salary and administrative responsibilities detract from interest. Among the matched sample of 96 R3s who also responded at Time 2 (55% response), non-chief residents had an increase in knowledge of and interest in the faculty role across the R3 year. CONCLUSIONS: Nearly half of senior family medicine residents report positive interest in residency faculty positions and in most components of the role. Mentorship may encourage more residents to consider these positions upon graduation or shortly thereafter. More research on other specialties and with career follow up is recommended.

Lack of Rule-Adherence During Mountain Gorilla Tourism Encounters in Bwindi Impenetrable National Park, Uganda, Places Gorillas at Risk From Human Disease.

Mountain gorillas (Gorilla beringei beringei) are an endangered primate species, with ~43% of the 1,063 individuals that remain on the planet today residing in Bwindi Impenetrable National Park (BINP) in southwestern Uganda. These primates are at the heart of a growing tourism industry that has incentivized their continued protection, but close proximity between humans and gorillas during such encounters presents well-documented risks for disease transmission. The Uganda Wildlife Authority (UWA) has developed rules to help protect the health of the gorillas, limiting each habituated gorilla group to a single 60 min visit each day by a group of no more than 8 tourists, and emphasizing that humans maintain a >7 m distance from gorillas at all times. A number of studies have documented that not all tour groups respect these rules. This project assesses rule-adherence during gorilla tourism encounters at BINP using both observational and survey-based data collected during the tourism high season between May and August, 2014. Observational data from 53 treks reveal that groups of 1-11 tourists engaged in gorilla viewing encounters between 46 and 98 min in duration. Although 96% of pre-trek briefings conducted by park rangers emphasized the need to maintain >7 m human-gorilla spacing, the 7 m distance rule was violated in over 98% (52 out of 53) of the tours examined in this study. Observational data were collected at 2 min intervals during gorilla-viewing encounters, documenting the nearest distance between any tourist and a gorilla (n = 1,604), of which 1,094 observations (68.2%) took place at a distance less than or equal to 7 m. Importantly, the 7 m rule was violated in visits to all of the gorilla groups habituated during the time of the study. In 224 observations (~14%, per 1,604 total), human-gorilla spacing was 3 m or less. Survey data (n = 243) revealed promising opportunities to improve tourist understanding of and adherence to park rules, with 73.6% of respondents indicating that they would be willing to utilize a precautionary measure of wearing a face-mask during encounters to protect gorilla health.

Associations Between Program-Level Abortion Training and Graduate Preparation for and Provision of Reproductive Care.

BACKGROUND AND OBJECTIVES: The role of training in the declining rate of family physicians' provision of women's reproductive health care is unclear. No requirements for abortion training exist, and curricula vary widely. This study assessed the impact of program-level abortion training availability on graduates' feelings of training adequacy and their postgraduate practice in reproductive health. METHODS: We conducted secondary analysis of graduate survey data from 18 family medicine residency programs in the Northwest categorized by whether or not their program routinely offered abortion training (opt out or elective rotation). We used bivariate analyses and logistic regression to compare groups on preparation for training and current clinical practice of women's health procedures. RESULTS: Six of 18 programs included in the study had routinely available abortion training for graduates (N=408). In bivariate analysis, these programs with routine abortion training had significantly more graduates who report feeling prepared to perform abortions (19% vs 10%; P=.01), but no difference in likelihood to provide abortion care postresidency compared to programs without routine abortion training. In adjusted analyses, graduates of programs with routine abortion training were significantly less likely to feel prepared for performing colposcopies (OR=0.45, 95% CI, 0.26-0.78; P<.01) and to actually perform them in practice (OR=0.32, 95% CI, 0.18-0.57; P<.001); all other differences are attenuated. CONCLUSIONS: Program-level abortion training alone is not enough to overcome the systems- and individual-level barriers to increasing the numbers of trained family medicine residency graduates who provide abortion care and other reproductive care in practice. More must be done to create opportunities for family physicians interested in providing full-spectrum care in their postgraduate practices to be able to do so.

Fossil lemurs from Egypt and Kenya suggest an African origin for Madagascar's aye-aye.

In 1967 G.G. Simpson described three partial mandibles from early Miocene deposits in Kenya that he interpreted as belonging to a new strepsirrhine primate, Propotto. This interpretation was quickly challenged, with the assertion that Propotto was not a primate, but rather a pteropodid fruit bat. The latter interpretation has not been questioned for almost half a century. Here we re-evaluate the affinities of Propotto, drawing upon diverse lines of evidence to establish that this strange mammal is a strepsirrhine primate as originally suggested by Simpson. Moreover, our phylogenetic analyses support the recognition of Propotto, together with late Eocene Plesiopithecus from Egypt, as African stem chiromyiform lemurs that are exclusively related to the extant aye-aye (Daubentonia) from Madagascar. Our results challenge the long-held view that all lemurs are descended from a single ancient colonization of Madagascar, and present an intriguing alternative scenario in which two lemur lineages dispersed from Africa to Madagascar independently, possibly during the later Cenozoic.

The first hyaenodont from the late Oligocene Nsungwe Formation of Tanzania: Paleoecological insights into the Paleogene-Neogene carnivore transition.

Throughout the Paleogene, most terrestrial carnivore niches in Afro-Arabia were occupied by Hyaenodonta, an extinct lineage of placental mammals. By the end of the Miocene, terrestrial carnivore niches had shifted to members of Carnivora, a clade with Eurasian origins. The transition from a hyaenodont-carnivore fauna to a carnivoran-carnivore fauna coincides with other ecological changes in Afro-Arabia as tectonic conditions in the African Rift System altered climatic conditions and facilitated faunal exchange with Eurasia. Fossil bearing deposits in the Nsungwe Formation in southwestern Tanzania are precisely dated to ~25.2 Ma (late Oligocene), preserving a late Paleogene Afro-Arabian fauna on the brink of environmental transition, including the earliest fossil evidence of the split between Old World monkeys and apes. Here we describe a new hyaenodont from the Nsungwe Formation, Pakakali rukwaensis gen. et sp. nov., a bobcat-sized taxon known from a portion of the maxilla that preserves a deciduous third premolar and alveoli of dP4 and M1. The crown of dP3 bears an elongate parastyle and metastyle and a small, blade-like metacone. Based on alveolar morphology, the two more distal teeth successively increased in size and had relatively large protocones. Using a hyaenodont character-taxon matrix that includes deciduous dental characters, Bayesian phylogenetic methods resolve Pakakali within the clade Hyainailouroidea. A Bayesian biogeographic analysis of phylogenetic results resolve the Pakakali clade as Afro-Arabian in origin, demonstrating that this small carnivorous mammal was part of an endemic Afro-Arabian lineage that persisted into the Miocene. Notably, Pakakali is in the size range of carnivoran forms that arrived and began to diversify in the region by the early Miocene. The description of Pakakali is important for exploring hyaenodont ontogeny and potential influences of Afro-Arabian tectonic events upon mammalian evolution, providing a deep time perspective on the stability of terrestrial carnivore niches through time.

Oligocene Termite Nests with In Situ Fungus Gardens from the Rukwa Rift Basin, Tanzania, Support a Paleogene African Origin for Insect Agriculture.

Based on molecular dating, the origin of insect agriculture is hypothesized to have taken place independently in three clades of fungus-farming insects: the termites, ants or ambrosia beetles during the Paleogene (66-24 Ma). Yet, definitive fossil evidence of fungus-growing behavior has been elusive, with no unequivocal records prior to the late Miocene (7-10 Ma). Here we report fossil evidence of insect agriculture in the form of fossil fungus gardens, preserved within 25 Ma termite nests from southwestern Tanzania. Using these well-dated fossil fungus gardens, we have recalibrated molecular divergence estimates for the origins of termite agriculture to around 31 Ma, lending support to hypotheses suggesting an African Paleogene origin for termite-fungus symbiosis; perhaps coinciding with rift initiation and changes in the African landscape.

A detailed assessment of the maxillary morphology of Limnopithecus evansi with implications for the taxonomy of the genus.

Limnopithecus is a small-bodied catarrhine genus that is widespread throughout early Miocene sites in East Africa. Although two species of this genus have been described - Limnopithecus legetet (type species) and Limnopithecus evansi - they are poorly known anatomically and their systematic positions remain unresolved. Here, we provide detailed descriptions and comparisons for two well-preserved maxillary specimens that we attribute to L. evansi. These specimens come from the type locality of the species, Songhor in western Kenya, and add greatly to our knowledge of its dentognathic morphology. Together, they preserve the entire unilateral upper dentition, with overlapping elements demonstrating conspecificity, and provide new information about I(2) morphology and aspects of the palate, nasal aperture, and maxillary sinuses. Detailed morphological comparisons suggest that specimens referred to Limnopithecus from Songhor, Koru, and Rusinga share a unique I(2) morphology not found in any other early Miocene catarrhine. This argues in favor of congeneric status for L. evansi and L. legetet. Moreover, features such as a broad palate, premolar morphology, and the relative proportions of the premolars of L. evansi distinguish it from Lomorupithecus harrisoni, another early Miocene catarrhine from Napak, Uganda. This finding challenges a recently proposed taxonomic interpretation that Lomorupithecus and L. evansi are conspecific. Our results underscore the distinctiveness of L. evansi and Lo. harrisoni, thereby reaffirming the validity of the taxon Lo. harrisoni and indicating that the Songhor and Napak catarrhine communities were relatively distinct, despite their apparent contemporaneity.

The earliest colubroid-dominated snake fauna from Africa: perspectives from the Late Oligocene Nsungwe Formation of southwestern Tanzania.

The extant snake fauna has its roots in faunal upheaval occurring across the Paleogene-Neogene transition. On northern continents, this turnover is well established by the late early Miocene. However, this transition is poorly documented on southern landmasses, particularly on continental Africa, where no late Paleogene terrestrial snake assemblages are documented south of the equator. Here we describe a newly discovered snake fauna from the Late Oligocene Nsungwe Formation in the Rukwa Rift Basin of Tanzania. The fauna is small but diverse with eight identifiable morphotypes, comprised of three booids and five colubroids. This fauna includes Rukwanyoka holmani gen. et sp. nov., the oldest boid known from mainland Africa. It also provides the oldest fossil evidence for the African colubroid clade Elapidae. Colubroids dominate the fauna, comprising more than 75% of the recovered material. This is likely tied to local aridification and/or seasonality and mirrors the pattern of overturn in later snake faunas inhabiting the emerging grassland environments of Europe and North America. The early emergence of colubroid dominance in the Rukwa Rift Basin relative to northern continents suggests that the pattern of overturn that resulted in extant faunas happened in a more complex fashion on continental Africa than was previously realized, with African colubroids becoming at least locally important in the late Paleogene, either ahead of or as a consequence of the invasion of colubrids. The early occurrence of elapid snakes in the latest Oligocene of Africa suggests the clade rapidly spread from Asia to Africa, or arose in Africa, before invading Europe.

Rewards and challenges of community health center practice.

BACKGROUND: More than 1100 community health centers (CHCs) in the United States provide primary care to 20 million underserved patients annually. CHCs have struggled to recruit and retain qualified physicians. OBJECTIVE: To understand physicians' work experiences in CHCs and identify major sources of satisfaction and dissatisfaction. METHODS: Using purposeful sampling, we conducted semistructured interviews with 12 family physicians practicing in CHCs. Interview questions assessed physicians' experiences in CHCs and sources of satisfaction and dissatisfaction. Interview notes were coded and analyzed by 2 investigators using a grounded theory approach to identify key themes. RESULTS: Though family physicians feel tremendous satisfaction from care of underserved patients, they are frustrated with the overwhelming workload they experience. Family physicians also report poor administrative management while working in CHCs. CONCLUSIONS: Implementation of the Affordable Care Act, which relies on expansion of CHC services, may be adversely affected by family physicians' frustrations with CHC practice. Further research to explore and potentially improve the CHC work environment may be needed.

"We have to what?": lessons learned about engaging support staff in an interprofessional intervention to implement MVA for management of spontaneous abortion.

BACKGROUND: Including support staff in practice change initiatives is a promising strategy to successfully implement new reproductive health services. The Resident Training Initiative in Miscarriage Management (RTI-MM) is an intervention designed to facilitate implementation of manual vacuum aspiration (MVA) for management of spontaneous abortion. The purpose of this study was to identify training program components that enhanced interprofessional training and provide lessons learned for engaging support staff in implementing uterine evacuation services. STUDY DESIGN: We conducted a secondary analysis of qualitative data to identify themes within three broad areas: interprofessional education, the role of support staff, and RTI-MM program components that facilitated support staff engagement in the process of implementing MVA services. RESULTS: We identified three key themes around interprofessional training and the role of support staff: "Training together is rare," "Support staff are crucial to practice change," and "Transparency, peers and champions." CONCLUSIONS: We present lessons learned that may be transferrable to other clinic sites: engage site leadership in a commitment to interprofessional training; engage support staff as teachers and learners and in shared values and building professionalism. IMPLICATIONS: This manuscript adds to what is known about how to employ interprofessional education and training to engage support staff in reproductive health services practice change initiatives. Lessons learned may provide guidance to clinical sites interested in interprofessional training, improving service delivery, or implementing new services.

Palaeontological evidence for an Oligocene divergence between Old World monkeys and apes.

Apes and Old World monkeys are prominent components of modern African and Asian ecosystems, yet the earliest phases of their evolutionary history have remained largely undocumented. The absence of crown catarrhine fossils older than ∼20 million years (Myr) has stood in stark contrast to molecular divergence estimates of ∼25-30 Myr for the split between Cercopithecoidea (Old World monkeys) and Hominoidea (apes), implying long ghost lineages for both clades. Here we describe the oldest known fossil 'ape', represented by a partial mandible preserving dental features that place it with 'nyanzapithecine' stem hominoids. Additionally, we report the oldest stem member of the Old World monkey clade, represented by a lower third molar. Both specimens were recovered from a precisely dated 25.2-Myr-old stratum in the Rukwa Rift, a segment of the western branch of the East African Rift in Tanzania. These finds extend the fossil record of apes and Old World monkeys well into the Oligocene epoch of Africa, suggesting a possible link between diversification of crown catarrhines and changes in the African landscape brought about by previously unrecognized tectonic activity in the East African rift system.

"One of those areas that people avoid" a qualitative study of implementation in miscarriage management.

BACKGROUND: Miscarriage is common and often managed by specialists in the operating room despite evidence that office-based manual vacuum aspiration (MVA) is safe, effective, and saves time and money. Family Medicine residents are not routinely trained to manage miscarriages using MVA, but have the potential to increase access to this procedure. This process evaluation sought to identify barriers and facilitators to implementation of office-based MVA for miscarriage in Family Medicine residency sites in Washington State. METHODS: The Residency Training Initiative in Miscarriage Management (RTI-MM) is a theory-based, multidimensional practice change initiative. We used qualitative methods to identify barriers and facilitators to successful implementation of the RTI-MM. RESULTS: Thirty-six RTI-MM participants completed an interview. We found that the common major barriers to implementation were low volume and a perception of miscarriage as emotional and/or like abortion, while the inclusion of support staff in training and effective champions facilitated successful implementation of MVA services. CONCLUSION: Perceived characteristics of the innovation that may conflict with cultural fit must be explicitly addressed in dissemination strategies and support staff should be included in practice change initiatives. Questions remain about how to best support champions and influence perceptions of the innovation. Our study findings contribute programmatically (to improve the RTI-MM), and to broader theoretical knowledge about practice change and implementation in health service delivery.

The family medicine residency training initiative in miscarriage management: impact on practice in Washington State.

BACKGROUND AND OBJECTIVES: Non-complicated spontaneous abortion cases should be counseled about the full range of management approaches, including uterine evacuation using manual vacuum aspiration (MVA). The Residency Training Initiative in Miscarriage Management (RTI-MM) is an intensive, multidimensional intervention designed to facilitate implementation of office-based management of spontaneous abortion using MVA in family medicine residency settings. The purpose of this study was to test the impact of the RTI-MM on self-reported use of MVA for management of spontaneous abortion. METHODS: We used a pretest/posttest one group study design and a web-based, anonymous survey to collect data on knowledge, attitudes, perceived barriers, and practice of office-based management of spontaneous abortion. We used multivariable models to estimate incident relative risks and accounted for data clustering at the residency site level. RESULTS: Our sample included 441 residents and faculty from 10 family medicine residency sites. Our findings show a positive association between the RTI-MM and self-reported use of MVA for management of spontaneous abortion (adjusted RR=9.11 [CI=4.20--19.78]) and were robust to model specification. Male gender, doing any type of management of spontaneous abortion (eg, expectant, medication), other on-site reproductive health training interventions, and support staff knowledge scores were also significant correlates of physician practice of MVA. CONCLUSIONS: Our findings suggest that the RTI-MM was successful in influencing the practice of management of spontaneous abortion using MVA in this population and that support staff knowledge may impact physician practice. Integrating MVA into family medicine settings would potentially improve access to evidence-based, comprehensive care for women.

Satisfaction of family physicians working in community health centers.

BACKGROUND: Community health centers (CHCs) receive $2.9 billion in federal funding to provide primary care to 20 million people annually, and these numbers are increasing. Understanding of physician satisfaction in CHCs may help guide recruitment and retention efforts aimed at expanding CHC programs. The objective of this study was to contrast the satisfaction of family physicians working in CHCs with the satisfaction of family physicians working in other practice settings. METHODS: Analysis of 4 cross-sectional surveys of recent residency graduates from the Washington, Wyoming, Alaska, Montana, and Idaho Family Medicine Residency Network. Surveys were conducted approximately every 3 years from 2000 to 2010. Main outcome measures included self-reported satisfaction with residency training, practice, and specialty on a 1 (low) to 5 (high) scale. RESULTS: Eight hundred ninety-three family physician responded (response rate, 61%), of whom 129 were CHC physicians and 764 were non-CHC physicians. Compared with non-CHC physicians, higher proportions of CHC physicians reported being highly satisfied with their residency training (79% vs 61%; P < .01) and choice of specialty (74% vs 60%; P < .01). In contrast, lower proportions of CHC physicians were highly satisfied with their employers (62% vs 72%; P = .05). [corrected]. There were no differences in satisfaction with practice partners, income, practice location, or work hours. After adjustment for physician, practice, and community characteristics, CHC physicians were more likely to be highly satisfied with their residency training (odds ratio, 2.6; P = .001) and their choice of specialty (odds ratio, 1.7; P = .03). CHC physicians were less likely to be highly satisfied with their employers (odds ratio, 0.5; P < .01). CONCLUSIONS: The lower level of satisfaction reported by CHC physicians has implications for workforce recruitment and retention in CHC settings. In an era of CHC growth, efforts to improve physician relationships with employers may be a potential target for enhancing the physician workforce in CHCs.

Diversity in the later Paleogene proboscidean radiation: a small barytheriid from the Oligocene of Dhofar Governorate, Sultanate of Oman.

Despite significant recent improvements to our understanding of the early evolution of the Order Proboscidea (elephants and their extinct relatives), geographic sampling of the group's Paleogene fossil record remains strongly biased, with the first ~30 million years of proboscidean evolution documented solely in near-coastal deposits of northern Africa. The considerable morphological disparity that is observable among the late Eocene and early Oligocene proboscideans of northern Africa suggests that other, as yet unsampled, parts of Afro-Arabia might have served as important centers for the early diversification of major proboscidean clades. Here we describe the oldest taxonomically diagnostic remains of a fossil proboscidean from the Arabian Peninsula, a partial mandible of Omanitherium dhofarensis (new genus and species), from near the base of the early Oligocene Shizar Member of the Ashawq Formation, in the Dhofar Governorate of the Sultanate of Oman. The molars and premolars of Omanitherium are morphologically intermediate between those of Arcanotherium and Barytherium from northern Africa, but its specialized lower incisors are unlike those of other known Paleogene proboscideans in being greatly enlarged, high-crowned, conical, and tusk-like. Omanitherium is consistently placed close to late Eocene Barytherium in our phylogenetic analyses, and we place the new genus in the Family Barytheriidae. Some features of Omanitherium, such as tusk-like lower second incisors, the possible loss of the lower central incisors, an enlarged anterior mental foramen, and inferred elongate mandibular symphysis and diminutive P(2), suggest a possible phylogenetic link with Deinotheriidae, an extinct family of proboscideans whose origins have long been mysterious.

The evolution of mammal-like crocodyliforms in the Cretaceous Period of Gondwana.

Fossil crocodyliforms discovered in recent years have revealed a level of morphological and ecological diversity not exhibited by extant members of the group. This diversity is particularly notable among taxa of the Cretaceous Period (144-65 million years ago) recovered from former Gondwanan landmasses. Here we report the discovery of a new species of Cretaceous notosuchian crocodyliform from the Rukwa Rift Basin of southwestern Tanzania. This small-bodied form deviates significantly from more typical crocodyliform craniodental morphologies, having a short, broad skull, robust lower jaw, and a dentition with relatively few teeth that nonetheless show marked heterodonty. The presence of morphologically complex, complementary upper and lower molariform teeth suggests a degree of crown-crown contact during jaw adduction that is unmatched among known crocodyliforms, paralleling the level of occlusal complexity seen in mammals and their extinct relatives. The presence of another small-bodied mammal-like crocodyliform in the Cretaceous of Gondwana indicates that notosuchians probably filled niches and inhabited ecomorphospace that were otherwise occupied by mammals on northern continents.

Too many referrals of low-risk women for BRCA1/2 genetic services by family physicians.

The increasing availability and public awareness of BRCA1/2 genetic testing will increase women's self-referrals to genetic services. The objective of this study was to examine whether patient characteristics influence the referral decisions of family physicians when a patient requests BRCA1/2 genetic testing. Family physicians (n = 284) completed a Web-based survey in 2006 to assess their attitudes and practices related to the use of genetics in their clinical practice. Using a 2 x 2 x 2 factorial design, we tested the effects of a hypothetical patient's race, level of worry, and insurance status on the decisions of family physicians to refer her for BRCA1/2 testing. The patient was not appropriate for referral based on U.S. Preventive Services Task Force guidelines. No patient characteristics were associated with the family physicians' referral decisions. Although referral was not indicated, only 8% did not refer to genetic services; 92% referred for genetic services, and 50% referred to genetic counseling. Family physicians regarded it unlikely that the patient carried a mutation, but 65% of family physicians believed that if they refused to refer for genetic services it would harm their relationship with the patient. Despite scarce and costly genetic services, family physicians were likely to inappropriately refer a low-risk patient who requested BRCA1/2 testing. The implications of this inappropriate referral on women's screening behavior, genetic services, and health care costs are unknown. Clinicians and patients could benefit from education about the appropriate use of genetic services so that both are more comfortable with a decision against referral.