RESUMEN
Pinnipeds (seals, sea lions, walruses, and their fossil relatives) are one of the most successful mammalian clades to live in the oceans. Despite a well-resolved molecular phylogeny and a global fossil record, a complete understanding of their macroevolutionary dynamics remains hampered by a lack of formal analyses that combine these two rich sources of information. We used a meta-analytic approach to infer the most densely sampled pinniped phylogeny to-date (36 recent and 93 fossil taxa) and used phylogenetic paleobiological methods to study their diversification dynamics and biogeographic history. Pinnipeds mostly diversified at constant rates. Walruses however experienced rapid turnover in which extinction rates ultimately exceeded speciation rates from 12-6 Ma, possibly due to changing sea-levels and/or competition with otariids (eared seals). Historical biogeographic analyses including fossil data allowed us to confidently identify the North Pacific and the North Atlantic (plus or minus Paratethys) as the ancestral ranges of Otarioidea (eared seals + walrus) and crown phocids (earless seals), respectively. Yet, despite the novel addition of stem pan-pinniped taxa, the region of origin for Pan-Pinnipedia remained ambiguous. These results suggest further avenues of study in pinnipeds and provide a framework for investigating other groups with substantial extinct and extant diversity.
RESUMEN
OBJECTIVES: This document offers guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents. SETTINGS AND PARTICIPANTS: Members of the telemedicine workgroup of AMDA-The Society for Post-Acute Long-Term Medicine-developed this guideline through both telephonic and face-to-face meetings between April 2017 and September 2018. The guideline is based on the currently available research, experience, and expertise of the workgroup's members, including a summary of a recently completed systematic mixed studies literature review to determine evidence for telemedicine to reduce emergency department visits or hospitalizations of nursing home residents. RESULTS: Research and experience to date support the use of telemedicine as a tool in change of condition assessment and management as a means of reducing unnecessary emergency department visits and hospitalization. Telemedicine-delivered care should be integrated into the primary care of the resident and delivered by providers with competency in post-acute long-term care. The development and sustainability of telemedicine programs is heavily dependent on financial implications. Quality measures should be defined for telemedicine programs in nursing homes. CONCLUSIONS/IMPLICATIONS: Telemedicine programs in nursing homes can contribute to the delivery of timely, high quality medical care, which reduces unnecessary hospitalization. Reimbursement for telemedicine-driven care should be based upon medical necessity of visits to care and the maintenance of quality standards. More studies are needed to understand which telemedicine tools and processes are most effective in improving outcomes for nursing home residents.
