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.

The phylogenomic and biogeographic history of the gartersnakes, watersnakes, and allies (Natricidae: Thamnophiini).

North American Thamnophiini (gartersnakes, watersnakes, brownsnakes, and swampsnakes) are an ecologically and phenotypically diverse temperate clade of snakes representing 61 species across 10 genera. In this study, we estimate phylogenetic trees using âˆ¼3,700 ultraconserved elements (UCEs) for 76 specimens representing 75% of all Thamnophiini species. We infer phylogenies using multispecies coalescent methods and time calibrate them using the fossil record. We also conducted ancestral area estimation to identify how major biogeographic boundaries in North America affect broadscale diversification in the group. While most nodes exhibited strong statistical support, analysis of concordant data across gene trees reveals substantial heterogeneity. Ancestral area estimation demonstrated that the genus Thamnophis was the only taxon in this subfamily to cross the Western Continental Divide, even as other taxa dispersed southward toward the tropics. Additionally, levels of gene tree discordance are overall higher in transition zones between bioregions, including the Rocky Mountains. Therefore, the Western Continental Divide may be a significant transition zone structuring the diversification of Thamnophiini during the Neogene and Pleistocene. Here we show that despite high levels of discordance across gene trees, we were able to infer a highly resolved and well-supported phylogeny for Thamnophiini, which allows us to understand broadscale patterns of diversity and biogeography.

Applying stochastic and Bayesian integral projection modeling to amphibian population viability analysis.

Integral projection models (IPMs) can estimate the population dynamics of species for which both discrete life stages and continuous variables influence demographic rates. Stochastic IPMs for imperiled species, in turn, can facilitate population viability analyses (PVAs) to guide conservation decision-making. Biphasic amphibians are globally distributed, often highly imperiled, and ecologically well suited to the IPM approach. Herein, we present a stochastic size- and stage-structured IPM for a biphasic amphibian, the U.S. federally threatened California tiger salamander (CTS) (Ambystoma californiense). This Bayesian model reveals that CTS population dynamics show greatest elasticity to changes in juvenile and metamorph growth and that populations are likely to experience rapid growth at low density. We integrated this IPM with climatic drivers of CTS demography to develop a PVA and examined CTS extinction risk under the primary threats of habitat loss and climate change. The PVA indicated that long-term viability is possible with surprisingly high (20%-50%) terrestrial mortality but simultaneously identified likely minimum terrestrial buffer requirements of 600-1000 m while accounting for numerous parameter uncertainties through the Bayesian framework. These analyses underscore the value of stochastic and Bayesian IPMs for understanding both climate-dependent taxa and those with cryptic life histories (e.g., biphasic amphibians) in service of ecological discovery and biodiversity conservation. In addition to providing guidance for CTS recovery, the contributed IPM and PVA supply a framework for applying these tools to investigations of ecologically similar species.

A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Development and validation of the patient centeredness index for primary care.

AIMS AND OBJECTIVES: To describe the development of the Patient Centeredness Index (PCI), evaluate its psychometric characteristics and evaluate the relationships between scores on the PCI and an established measure of empathy. BACKGROUND: Patient centeredness helps patients manage multiple chronic conditions with their providers, nurses and other team members. However, no instrument exists for evaluating patient centeredness within primary care practices treating this population. DESIGN: Multi-site instrument development and validation. STROBE reporting guidelines were followed. METHODS: To identify themes, we consulted literature on patient centeredness and engaged stakeholders who had or were caring for people with multiple chronic conditions (n = 7). We composed and refined items to represent those themes with input from clinicians and researchers. To evaluate reliability and convergent validity, we administered surveys to participants (n = 3622) with chronic conditions recruited from 44 primary care practices for a large-scale cluster randomised clinical trial of the effects of a practice-level intervention on patient and practice-level outcomes. Participants chose to complete the 16-item survey online, on paper or by phone. Surveys assessed demographics, number of chronic conditions and ratings of provider empathy. We conducted exploratory factor analysis to model the interrelationships among items. RESULTS: A single factor explained 93% of total variance. Factor loadings ranged from 0.55-0.85, and item-test correlations were ≥.67. Cronbach's alpha was .93. A moderate, linear correlation with ratings of provider's empathy (r = .65) supports convergent validity. CONCLUSIONS: The PCI is a new tool for obtaining patient perceptions of the patient centeredness of their primary care practice. The PCI shows acceptable reliability and evidence of convergent validity among patients managing chronic conditions. RELEVANCE TO CLINICAL PRACTICE: The PCI rapidly identifies patients' perspectives on patient centeredness of their practice, making it ideal for administration in busy primary care settings that aim to efficiently address patient-identified needs. TRIAL REGISTRATION: Clinicaltrials.org Protocol ID: WLPS-1409-24372. TITLE: Integrating Behavioural Health and Primary Care for Comorbid Behavioural and Medical Problems (IBHPC).

Existential distress and meaning making among female breast cancer patients with cancer-related fertility concerns.

OBJECTIVES: The current study explored the impact of cancer-related fertility concerns on existential distress and meaning making among female breast cancer (BC) patients of childbearing age and assessed support needs. METHODS: The current study was embedded within a larger study. A seven-question online survey was administered to female BC participants to explore meaning and identity in their lives. Applied thematic analysis was used to analyze participants' written responses. RESULTS: A total of 98 participants completed the survey, the majority of whom identified as white, married or partnered, and employed full time and with stage I or II BC. More than 50% of the participants expressed a need for support from a counselor or support group during their cancer experience. Three subthemes emerged related to existential distress and cancer-related fertility concerns: (1) loss of womanhood: treatment-related physical changes impact on gender identity; (2) existential distress due to treatment decisions impacting fertility; and (3) shattered vision: cancer-related infertility impact on meaning and purpose. Four subthemes emerged related to meaning making with fertility-related existential concerns: (1) coping with loss of meaning, (2) re-evaluating priorities in life; (3) resilience to loss, and (4) persistent loss of meaning. SIGNIFICANCE OF RESULTS: Study results offer valuable insights into the experiences of female BC survivors' cancer-related fertility on existential distress and meaning making. Development of psychological interventions targeted to support this population to cope with existential distress due to cancer-related fertility concerns and meaning making are needed to improve the quality of life of this population.

Conjugated Polyelectrolyte-Based Complex Fluids as Aqueous Exciton Transport Networks.

The ability to assemble artificial systems that mimic aspects of natural light-harvesting functions is fascinating and attractive for materials design. Given the complexity of such a system, a simple design pathway is desirable. Here, we argue that associative phase separation of oppositely charged conjugated polyelectrolytes (CPEs) can provide such a path in an environmentally benign medium: water. We find that complexation between an exciton-donor and acceptor CPE leads to formation of a complex fluid. We interrogate exciton transfer from the donor to the acceptor CPE within the complex fluid and find that transfer is highly efficient. We also find that excess molecular ions can tune the modulus of the inter-CPE complex fluid. Even at high ion concentrations, CPEs remain complexed with significantly delocalized electronic wavefunctions. Our work lays the rational foundation for complex, tunable aqueous light-harvesting systems via the intrinsic thermodynamics of associative phase separation.

Early Trajectories of Patient Reported Outcomes in Breast Cancer Patients Undergoing Lumpectomy Versus Mastectomy.

PURPOSE: This study was designed to: (1) characterize longitudinal patient-reported outcomes (PROs) between breast cancer patients undergoing lumpectomy and mastectomy and (2) compare return to baseline scores at 3 months and 6 months postoperatively. METHODS: Newly diagnosed breast cancer patients seen at an academic breast center between June 2019 and February 2021 were invited to participate in longitudinal PRO surveys at their initial clinic visit. If willing to participate, patients were emailed the validated BREAST-Q™ questionnaire at the initial clinic visit (baseline), 2 weeks after surgery, and then every 3 months for the first year. We used linear mixed models to estimate the differences in slopes over time between lumpectomy and mastectomy for each PRO measure. Pearson's Chi-square tests with Yates' continuity correction were used to compare proportions of patients who return to baseline PRO scores. P < 0.05 was considered significant. RESULTS: Of 164 patients invited to participate, 100 (61%) completed a baseline survey and were included in analyses. Mastectomy patients had significantly greater decreases in breast satisfaction (P = 0.002), psychosocial well-being (P < 0.0001), and sexual well-being (P < 0.0001) over time compared with lumpectomy patients. Both surgical groups reported a decrease in physical well-being, although the decline was more significant in lumpectomy patients (P = 0.005). At 3 months and 6 months after surgery, significantly larger proportions of lumpectomy patients returned to their baseline breast satisfaction, psychosocial well-being, and physical well-being compared with mastectomy patients. CONCLUSIONS: Understanding how outcomes important to patients change over the care continuum can provide opportunities for early intervention and may prevent debilitating long-term morbidities of treatment.

Impact of age mismatch between donor and recipient on heart transplant mortality.

The effect of donor-to-recipient (D-R) age mismatch in adult heart transplant population is not clearly described, and we undertook this study to determine the impact of age mismatch on mortality. Heart transplant recipients from 2000 to 2017 were identified using the United Network of Organ Sharing database. The cohort was divided into three groups: donor age within 5 years of recipient age (Group 1), donors >5 years younger than recipient (group 2), and donors >5 years older than recipients (Group 3). We also evaluated if this finding changed by recipient age. Twenty eight thousand, four hundred and eleven patients met the inclusion criteria. Compared to group 1, the adjusted hazard ratio (aHR) for mortality for group 2 was 0.91 (0.83-0.99, p value <.039) and for group 3 was 1.36 (1.21-1.52, p value <.001); however, when looking at recipient age as continuous variable, receiving a younger heart was protective only for recipients younger than 45 years of age, and receiving a heart transplant from an older donor was detrimental only in recipients aged 25-35.

Nonlinear relationship between nonresidential destinations and body mass index across a wide range of development.

BACKGROUND: Destination accessibility is an important measure of the built environment that is associated with active transport and body mass index (BMI). In higher density settings, an inverse association has been consistently found, but in lower density settings, findings are limited. We previously found a positive relationship between the density of nonresidential destinations (NRD) and BMI in a low-density state. We sought to test the generalizability of this unexpected finding using data from six other states that include a broader range of settlement densities. METHODS: We obtained the address, height, and weight of 16.9 million residents with a driver's license or state identification cards, as well as the location of 3.8 million NRDs in Washington, Oregon, Texas, Illinois, Michigan, and Maine from Dun & Bradstreet. We tested the association between NRDs∙ha-1 within 1 km of the home address, and self-reported BMI (kg∙m-2). Visualization by locally-weighted smoothing curves (LOWESS) revealed an inverted U-shape. A multivariable piecewise regression with a random intercept for state was used to assess the relationship. RESULTS: After accounting for age, sex, year of issue, and census tract social and economic variables, BMI correlated positively with NRDs in the low-to-mid density stratum (ß = +0.005 kg∙m-2/nonresidential building∙ha-1; 95% CI: +0.004,+0.006) and negatively in the mid-to-high density stratum (ß = -0.002; 95% CI: -0.004,-0.0003); a significant difference in slopes (P < 0.001). CONCLUSIONS: BMI peaked in the middle density, with lower values in both the low and high-density extremes. These results suggest that the mechanisms by which NRDs are associated with obesity may differ by density level.

Impact of changing renal function, while waiting for a heart transplant, on post-transplant mortality and development of end stage kidney disease.

Heart transplantation is a viable option for end stage heart disease but long-term complications such as chronic kidney disease are being increasingly recognized. We sought to investigate the effect of change in estimated glomerular filtration rate (eGFR) during the heart transplant waitlist period on post-transplant mortality and end stage kidney disease (ESKD). We analysed the United Network of Organ Sharing heart transplant database from 2000 to 2017. Multivariable Cox regression with restricted cubic splines and cumulative incidence competing risk (CICR) methods were used to compare the effects of change in eGFR on mortality and ESKD, respectively. A total of 19 412 patients met our inclusion criteria. Mortality increased with increasing loss of eGFR (adjusted hazard ratio increased from 1.02 [confidence interval (CI) 1.01-1.04, P = 0.008] for 10% loss to 1.15 (CI 1.06-1.26, P = 0.001) for 50% loss of eGFR. Similarly, risk of ESKD also increased monotonically with increasing loss of renal function [subdistribution hazard ratio increased from 1.12 (CI 1.09-1.14, P < 0.001) to 2.0 (CI 1.74-2.3, P < 0.001)] as loss of eGFR increased from 10% to 50%. Overall, we found that loss of >10% of eGFR resulted in higher risk of mortality and higher risk of ESKD.

Quantum Chemistry Common Driver and Databases (QCDB) and Quantum Chemistry Engine (QCEngine): Automation and interoperability among computational chemistry programs.

Community efforts in the computational molecular sciences (CMS) are evolving toward modular, open, and interoperable interfaces that work with existing community codes to provide more functionality and composability than could be achieved with a single program. The Quantum Chemistry Common Driver and Databases (QCDB) project provides such capability through an application programming interface (API) that facilitates interoperability across multiple quantum chemistry software packages. In tandem with the Molecular Sciences Software Institute and their Quantum Chemistry Archive ecosystem, the unique functionalities of several CMS programs are integrated, including CFOUR, GAMESS, NWChem, OpenMM, Psi4, Qcore, TeraChem, and Turbomole, to provide common computational functions, i.e., energy, gradient, and Hessian computations as well as molecular properties such as atomic charges and vibrational frequency analysis. Both standard users and power users benefit from adopting these APIs as they lower the language barrier of input styles and enable a standard layout of variables and data. These designs allow end-to-end interoperable programming of complex computations and provide best practices options by default.

A cumulative risk index for use in the medical home.

BACKGROUND AND OBJECTIVE: Previous studies have described the effect of sociodemographic factors on early development. We describe development of a simple cumulative risk index (CRI) based on four sociodemographic factors and explore the concurrent and predictive relationship of this index to a measure of the cognitive home environment in early childhood and to later school functioning. METHODS: This was a secondary data analysis of children from an urban pediatrics clinic. Baseline data were collected at 10-23 months (n = 324) with primary follow-up 6 months later at 18-35 months (n = 179) and secondary follow-up at 8-10 years (n = 68). A CRI score was derived at baseline using maternal education, marital status, race/ethnicity and child insurance. Baseline and primary follow-up included three subscales of the STIMQ, a measure of the cognitive home environment. Effectiveness of CRI was examined using analysis of variance (ANOVA) with linear contrasts. Chi-square examined differences in school function between children from CRI high-risk (CRI 3-4) and low-risk (CRI 0-2) families. RESULTS: CRI had a negative impact in early childhood on STIMQ subscale scores (p < 0.007-0.05) that increased as the number of risk factors increased (p < 0.05). Significantly more children from high-risk families (CRI 3-4) were rated as having poor school performance than children from low-risk families (CRI 0-2) (p < 0.05). CONCLUSIONS: We showed that a practice-friendly CRI, based on characteristics typically available in the medical record, could help identify families less likely to support development concurrently at 1 year of age and predictively at 2-3 years. School functioning at 8 to 10 years was also significantly better in children with a low CRI at 1 year. The CRI could be a useful tool for both clinicians and researchers needing a simple tool for risk assessment.

A multifunctional matching algorithm for sample design in agricultural plots.

Collection of accurate and representative data from agricultural fields is required for efficient crop management. Since growers have limited available resources, there is a need for advanced methods to select representative points within a field in order to best satisfy sampling or sensing objectives. The main purpose of this work was to develop a data-driven method for selecting locations across an agricultural field given observations of some covariates at every point in the field. These chosen locations should be representative of the distribution of the covariates in the entire population and represent the spatial variability in the field. They can then be used to sample an unknown target feature whose sampling is expensive and cannot be realistically done at the population scale. An algorithm for determining these optimal sampling locations, namely the multifunctional matching (MFM) criterion, was based on matching of moments (functionals) between sample and population. The selected functionals in this study were standard deviation, mean, and Kendall's tau. An additional algorithm defined the minimal number of observations that could represent the population according to a desired level of accuracy. The MFM was applied to datasets from two agricultural plots: a vineyard and a peach orchard. The data from the plots included measured values of slope, topographic wetness index, normalized difference vegetation index, and apparent soil electrical conductivity. The MFM algorithm selected the number of sampling points according to a representation accuracy of 90% and determined the optimal location of these points. The algorithm was validated against values of vine or tree water status measured as crop water stress index (CWSI). Algorithm performance was then compared to two other sampling methods: the conditioned Latin hypercube sampling (cLHS) model and a uniform random sample with spatial constraints. Comparison among sampling methods was based on measures of similarity between the target variable population distribution and the distribution of the selected sample. MFM represented CWSI distribution better than the cLHS and the uniform random sampling, and the selected locations showed smaller deviations from the mean and standard deviation of the entire population. The MFM functioned better in the vineyard, where spatial variability was larger than in the orchard. In both plots, the spatial pattern of the selected samples captured the spatial variability of CWSI. MFM can be adjusted and applied using other moments/functionals and may be adopted by other disciplines, particularly in cases where small sample sizes are desired.

Housing and accessibility after the COVID-19 pandemic: Rebuilding for resilience, equity and sustainable mobility.

A more sustainable post COVID-19 world requires urban transport policies aiming for resilience, social equity and decarbonisation. Instead of just focusing on the transport sector, the authors propose an integrated approach to housing and mobility. This approach acknowledges the challenges posed by inadequate housing and dependence on motorised transport during the COVID-19 crisis. In contrast, adequate housing and cycling became paramount resources while confronting the pandemic. Using Santiago de Chile as a case study, this research examines how different relocation scenarios for its current housing deficit cannot only affect the ability to implement stay-at-home measures, but also the potential of cycling as a relevant commuting alternative. The current location of the families suffering this deficit is compared to three scenarios: compact, pericentral and extended. In light of the learnings from the COVID-19 crisis, a housing-cycling policy becomes a tool for resilience; equity is achieved by enforcing the right to housing, by increasing job opportunities among the poor, and by reducing the dependence on expensive motorised transport; decarbonisation is achieved by promoting active transportation and reducing the dependence on motorisation.

Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study.

BACKGROUND: Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery. MATERIALS AND METHODS: We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis. RESULTS: One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription. CONCLUSIONS: Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.

Cumulative risk, the cognitive home environment and vocabulary in early childhood.

INTRODUCTION: Early home support for language development is critical for later developmental progress. Paediatricians have the opportunity to identify families at risk of failing to provide this support in infancy but often lack simple tools to do so. This study explores the potential of a simple count of sociodemographic risk factors, a cumulative risk (CR) index, to identify families likely to need help in providing literacy support from an early age. METHODS: CR scores were calculated for 308 families who completed the STIMQ and MacArthur Communicative Development Inventory (MCDI) at 11-15 months) and 197 (64%) again at 23-37 months. Analysis of variance with linear contrasts examined the effect of CR on the STIMQ and the MCDI at baseline and follow-up. Correlation analysis explored the relationship between STIMQ and MCDI. RESULTS: At both baseline and follow-up, CR index showed a significant effect (p<0.006) on the STIMQ along with a significant linear trend for STIMQ scores to decrease as CR increased (p<0.05-0.005). No significant effects of CR effects on MCDI were observed at baseline or follow-up, whereas MCDI percentiles correlated significantly (p<0.03-0.001) with STIMQ scores (r=0.18-0.26.) at both times. CONCLUSIONS: The CR index is a simple tool that can help identify families needing support for providing a language stimulating home environment in the first 2 years before long-term ill effects of sociodemographic barriers are established.

Phylogeography of a widespread lizard complex reflects patterns of both geographic and ecological isolation.

A primary challenge for modern phylogeography is understanding how ecology and geography, both contemporary and historical, shape the spatial distribution and evolutionary histories of species. Phylogeographic patterns are the result of many factors, including geology, climate, habitat, colonization history and lineage-specific constraints. Assessing the relative influences of these factors is difficult because few species, regions and environments are sampled in enough detail to compare competing hypotheses rigorously and because a particular phylogeographic pattern can potentially result from different evolutionary scenarios. The silky anoles (Anolis sericeus complex) of Central America and Mexico are abundant and found in all types of lowland terrestrial habitat, offering an excellent opportunity to test the relative influences of the factors affecting diversification. Here, we performed a range-wide statistical phylogeographic analysis on restriction site-associated DNA (RAD) markers from silky anoles and compared the phylogeographic patterns we recovered to historical and contemporary environmental and topographic data. We constructed niche models to compare niche overlap between sister lineages and conducted coalescent simulations to characterize how the major lineages of silky anoles have diverged. Our results revealed that the mode of divergence for major lineage diversification events was geographic isolation, resulting in ecological divergence between lineages, followed by secondary contact. Moreover, comparisons of parapatric sister lineages suggest that ecological niche divergence contributed to isolation by environment in this system, reflecting the natural history differences among populations in divergent environments.

Self-insertion of foreign bodies into the orbit and periocular tissue.

We describe six patients with 12 separate episodes of self-inflicted periocular foreign body injuries, which presented to our institution recently. All patients were male, relatively young (mean 28.5 years old), incarcerated, and had significant underlying psychiatric conditions. The subjects had inserted staples (6), paperclips (2), or other small metallic wire segments (4) into the periocular region. Most cases (9/12) involved concurrent self-inflicted injury to other body parts. Ten cases involved foreign bodies inserted through the palpebral conjunctiva into the upper eyelid, while two cases involved insertion into the orbit. Identification and surgical retrieval of foreign bodies was successful in most cases (9/11) but was not attempted in one case. Self-inflicted periocular injuries, while rare, are challenging cases for which the ophthalmologist should be prepared. A multidisciplinary approach, including psychiatric assessment and treatment, is important for optimal care.

Sudden-onset Blindness from a Spontaneous Carotid-cavernous Fistula with Secondary Central Retinal Artery Occlusion and Posterior Ischemic Optic Neuropathy.

Our case describes a patient diagnosed with a carotid-cavernous fistula (CCF) secondary to a spontaneously ruptured cavernous carotid aneurysm, presenting with sudden vision loss, and a concomitant central retinal artery occlusion as visualized by a cherry-red spot in the macula and posterior ischemic optic neuropathy. Computed tomography of the brain and orbits showed mild hydrocephalus, orbital fat haziness, and proptosis with concern for fluid in the basal cisterns. Cerebral angiography confirmed the suspected diagnosis of CCF. After angiography, a Magnetic resonance imaging of the brain demonstrated abnormal diffusion restriction in the posterior right optic nerve confirmed on the apparent diffusion coefficient map, consistent with ischemia of the optic nerve in this location. Two weeks after discharge, outpatient fundus photography showed resolution of her cherry-red spot, and optical coherence tomography showed thinning of the entire retinal nerve fiber layer as compared to the contralateral eye. In CCFs, congestive symptoms of proptosis, pain, and even central retinal vein occlusion findings are frequently described. However, our patient's no light perception vision and imaging findings suggest associated central retinal artery occlusion and ischemic optic neuropathy. These findings underscore the multitude of serious visual effects of high flow CCFs.