Use of Stroboscopic Goggles in Suture Training Improves Precision and Accuracy.

BACKGROUND: This study aimed to quantify the impact of intermittent visual occlusion via stroboscopic goggles on suture accuracy and precision. METHODS: This crossover study recruited and randomized 72 graduate students to train with stroboscopic goggles early or late in structured suture practice. Participants completed assessments of 10 running sutures with 2 training sessions between baseline and follow-up assessments. The procedure was repeated after crossover. Suture photos were analyzed using ImageJ. Total error among all measurements represented accuracy; standard deviation of error represented precision. Intra- and inter-group trends were identified with Wilcoxon rank-sum tests. RESULTS: Both groups significantly improved in accuracy in the sessions immediately following goggle use, but the group that used goggles later in training continued improving in accuracy and precision while the group that trained with stroboscopic goggles early plateaued. CONCLUSIONS: Using stroboscopic goggles showed quantifiable benefit for augmenting suture training with greatest effect after initial skill acquisition is completed.

Impacts of longleaf pine (Pinus palustris Mill.) on long-term hydrology at the watershed scale.

Threats from climate change and growing populations require innovative solutions for restoring streamflow in many regions. In the arid western U.S., attempts to increase streamflow (Q) through forest management have had mixed results, but these approaches may be more successful in the eastern U.S. where greater precipitation (P) and lower evapotranspiration (ET) offer greater potential to increase Q by reducing ET. Longleaf pine (Pinus palustris Mill.) (LLP) woodlands, once the dominant land cover in the southeastern United States, often have lower ET than other forest types but it is unclear how longleaf pine cover impacts watershed-scale hydrology. To address this question, we analyzed 21 gaged rural watersheds. We estimated annual water balance ET (ETwb) as the difference between precipitation (P) and streamflow (Q) between 1989 and 2021 and quantified low flow rates (7Q10) among watersheds with high and low LLP cover. To control for climate variability among watersheds, we compared variation in hydrology metrics with biotic and abiotic variables using the Budyko equation (ETBudyko) to understand the differences between the two ET estimates (∆ET). Watersheds with 15-72 % LLP cover had 17 % greater mean annual Q, 7 % lower annual ETwb, and 92 % greater 7Q10 low flow rates than watersheds with <3 % LLP. LLP cover decreased ET and increased Q by 2.4 mm or 0.15 % Q/P per 1 % of watershed area, but only when LLP was managed as open woodlands. Our results demonstrate that ecological forest restoration in these systems, which entails mechanical thinning and re-introduction of low-intensity prescribed fire to maintain open woodlands, and enhance understory diversity, can contribute to decreases in ET and increases in Q in eastern forests.

Integration of Improvement and Implementation Science in Practice-Based Research Networks: a Longitudinal, Comparative Case Study.

BACKGROUND: Implementation science (IS) and quality improvement (QI) inhabit distinct areas of scholarly literature, but are often blended in practice. Because practice-based research networks (PBRNs) draw from both traditions, their experience could inform opportunities for strategic IS-QI alignment. OBJECTIVE: To systematically examine IS, QI, and IS/QI projects conducted within a PBRN over time to identify similarities, differences, and synergies. DESIGN: Longitudinal, comparative case study of projects conducted in the Oregon Rural Practice-based Research Network (ORPRN) from January 2007 to January 2019. APPROACH: We reviewed documents and conducted staff interviews. We classified projects as IS, QI, IS/QI, or other using established criteria. We abstracted project details (e.g., objective, setting, theoretical framework) and used qualitative synthesis to compare projects by classification and to identify the contributions of IS and QI within the same project. KEY RESULTS: Almost 30% (26/99) of ORPRN's projects included IS or QI elements; 54% (14/26) were classified as IS/QI. All 26 projects used an evidence-based intervention and shared many similarities in relation to objective and setting. Over half of the IS and IS/QI projects used randomized designs and theoretical frameworks, while no QI projects did. Projects displayed an upward trend in complexity over time. Project used a similar number of practice change strategies; however, projects classified as IS predominantly employed education/training while all IS/QI and most QI projects used practice facilitation. Projects including IS/QI elements demonstrated the following contributions: QI provides the mechanism by which the principles of IS are operationalized in order to support local practice change and IS in turn provides theories to inform implementation and evaluation to produce generalizable knowledge. CONCLUSIONS: Our review of projects conducted over a 12-year period in one PBRN demonstrates key synergies for IS and QI. Strategic alignment of IS/QI within projects may help improve care quality and bridge the research-practice gap.

Warmer temperatures reduce net carbon uptake, but do not affect water use, in a mature southern Appalachian forest.

Increasing air temperature is expected to extend growing season length in temperate, broadleaf forests, leading to potential increases in evapotranspiration and net carbon uptake. However, other key processes affecting water and carbon cycles are also highly temperature-dependent. Warmer temperatures may result in higher ecosystem carbon loss through respiration and higher potential evapotranspiration through increased atmospheric demand for water. Thus, the net effects of a warming planet are uncertain and highly dependent on local climate and vegetation. We analyzed five years of data from the Coweeta eddy covariance tower in the southern Appalachian Mountains of western North Carolina, USA, a highly productive region that has historically been underrepresented in flux observation networks. We examined how leaf phenology and climate affect water and carbon cycling in a mature forest in one of the wettest biomes in North America. Warm temperatures in early 2012 caused leaf-out to occur two weeks earlier than in cooler years and led to higher seasonal carbon uptake. However, these warmer temperatures also drove higher winter ecosystem respiration, offsetting much of the springtime carbon gain. Interannual variability in net carbon uptake was high (147 to 364 g C m-2 y-1), but unrelated to growing season length. Instead, years with warmer growing seasons had 10% higher respiration and sequestered ~40% less carbon than cooler years. In contrast, annual evapotranspiration was relatively consistent among years (coefficient of variation = 4%) despite large differences in precipitation (17%, range = 800 mm). Transpiration by the evergreen understory likely helped to compensate for phenologically-driven differences in canopy transpiration. The increasing frequency of high summer temperatures is expected to have a greater effect on respiration than growing season length, reducing forest carbon storage.

Declining water yield from forested mountain watersheds in response to climate change and forest mesophication.

Climate change and forest disturbances are threatening the ability of forested mountain watersheds to provide the clean, reliable, and abundant fresh water necessary to support aquatic ecosystems and a growing human population. Here, we used 76 years of water yield, climate, and field plot vegetation measurements in six unmanaged, reference watersheds in the southern Appalachian Mountains of North Carolina, USA to determine whether water yield has changed over time, and to examine and attribute the causal mechanisms of change. We found that annual water yield increased in some watersheds from 1938 to the mid-1970s by as much as 55%, but this was followed by decreases up to 22% by 2013. Changes in forest evapotranspiration were consistent with, but opposite in direction to the changes in water yield, with decreases in evapotranspiration up to 31% by the mid-1970s followed by increases up to 29% until 2013. Vegetation survey data showed commensurate reductions in forest basal area until the mid-1970s and increases since that time accompanied by a shift in dominance from xerophytic oak and hickory species to several mesophytic species (i.e., mesophication) that use relatively more water. These changes in forest structure and species composition may have decreased water yield by as much as 18% in a given year since the mid-1970s after accounting for climate. Our results suggest that changes in climate and forest structure and species composition in unmanaged forests brought about by disturbance and natural community dynamics over time can result in large changes in water supply.

Two fixation methods for acromioclavicular joint reduction during coracoclavicular ligament reconstruction: a biomechanical analysis.

One specimen from each of six pairs of cadaveric shoulders underwent a semitendinosus coracoclavicular ligament reconstruction with a hook plate used for acromioclavicular joint reduction, while on the other specimen a polydioxanone (PDS) suture braid was utilized. Cyclical loading followed by maximal load-to-failure testing was performed. Displacement during cyclical loading, loads to 50% and 100% displacement, stiffness, and maximal load to failure were determined for all specimens. Results showed that the locking hook plate allowed significantly less displacement of the coracoclavicular interval during cyclical loading (3.41 vs. 9.67 mm, p = .0081) and withstood significantly higher loads before both 50% (225.5 vs. 107.7 N, p = .0197) and 100% displacement (410.6 vs. 240.1 N, p = .0077). The locking hook plate was found to be significantly stiffer than the PDS suture braid (28.2 vs. 18.4 N/mm, p = .0029), but there was no difference in maximal load to failure between the two fixation methods (hook plate, 434.4 N; PDS, 476.7 N; p = .76).

Barrier island morphology and sediment characteristics affect the recovery of dune building grasses following storm-induced overwash.

Barrier islands are complex and dynamic systems that provide critical ecosystem services to coastal populations. Stability of these systems is threatened by rising sea level and the potential for coastal storms to increase in frequency and intensity. Recovery of dune-building grasses following storms is an important process that promotes topographic heterogeneity and long-term stability of barrier islands, yet factors that drive dune recovery are poorly understood. We examined vegetation recovery in overwash zones on two geomorphically distinct (undisturbed vs. frequently overwashed) barrier islands on the Virginia coast, USA. We hypothesized that vegetation recovery in overwash zones would be driven primarily by environmental characteristics, especially elevation and beach width. We sampled species composition and environmental characteristics along a continuum of disturbance from active overwash zones to relict overwash zones and in adjacent undisturbed environments. We compared species assemblages along the disturbance chronosequence and between islands and we analyzed species composition data and environmental measurements with Canonical Correspondence Analysis to link community composition with environmental characteristics. Recovering and geomorphically stable dunes were dominated by Ammophila breviligulata Fernaud (Poaceae) on both islands while active overwash zones were dominated by Spartina patens (Aiton) Muhl. (Poaceae) on the frequently disturbed island and bare sand on the less disturbed island. Species composition was associated with environmental characteristics only on the frequently disturbed island (p = 0.005) where A. breviligulata was associated with higher elevation and greater beach width. Spartina patens, the second most abundant species, was associated with larger sediment grain size and greater sediment size distribution. On the less frequently disturbed island, time since disturbance was the only factor that affected community composition. Thus, factors driving the abundance of dune-building grasses and subsequent recovery of dunes varied between the two geomorphically distinct islands.

Future species composition will affect forest water use after loss of eastern hemlock from southern Appalachian forests.

Infestation of eastern hemlock (Tsuga canadensis (L.) Carr.) with hemlock woolly adelgid (HWA, Adelges tsugae) has caused widespread mortality of this key canopy species throughout much of the southern Appalachian Mountains in the past decade. Because eastern hemlock is heavily concentrated in riparian habitats, maintains a dense canopy, and has an evergreen leaf habit, its loss is expected to have a major impact on forest processes, including transpiration (E(t)). Our goal was to estimate changes in stand-level E(t) since HWA infestation, and predict future effects of forest regeneration on forest E(t) in declining eastern hemlock stands where hemlock represented 50-60% of forest basal area. We used a combination of community surveys, sap flux measurements, and empirical models relating sap flux-scaled leaf-level transpiration (E(L)) to climate to estimate the change in E(t) after hemlock mortality and forecast how forest E(t) will change in the future in response to eastern hemlock loss. From 2004 to 2011, eastern hemlock mortality reduced annual forest E(t) by 22% and reduced winter E(t) by 74%. As hemlock mortality increased, growth of deciduous tree species--especially sweet birch (Betula lenta L.), red maple (Acer rubrum L.), yellow poplar (Liriodendron tulipifera L.), and the evergreen understory shrub rosebay rhododendron (Rhododendron maximum L.)--also increased, and these species will probably dominate post-hemlock riparian forests. All of these species have higher daytime E(L) rates than hemlock, and replacement of hemlock with species that have less conservative transpiration rates will result in rapid recovery of annual stand E(t). Further, we predict that annual stand E(t) will eventually surpass E(t) levels observed before hemlock was infested with HWA. This long-term increase in forest E(t) may eventually reduce stream discharge, especially during the growing season. However, the dominance of deciduous species in the canopy will result in a permanent reduction in winter E(t) and possible increase in winter stream discharge. The effects of hemlock die-off and replacement with deciduous species will have a significant impact on the hydrologic flux of forest transpiration, especially in winter. These results highlight the impact that invasive species can have on landscape-level ecosystem fluxes.

Contribution of sunflecks is minimal in expanding shrub thickets compared to temperate forest.

Ecological consequences of shrub encroachment are emerging as a key issue in the study of global change. In mesic grasslands, shrub encroachment can result in a fivefold increase in ecosystem leaf area index (LAI) and a concurrent reduction in understory light and herbaceous diversity. LAI and light attenuation are often higher for shrub thickets than for forest communities in the same region, yet little is known about the contribution of sunflecks in shrub-dominated systems. Our objective was to compare fine-scale spatial and temporal dynamics of understory light in shrub thickets to the light environment in typical forest communities. We used an array of quantum sensors to examine variation in diffuse and direct light and determined the relative contribution of sunflecks during midday in Morella cerifera shrub thickets, a 30-yr-old abandoned Pinus taeda plantation, and a mature, second-growth, deciduous forest. Instantaneous photosynthetic photon flux density (PPFD) was measured at 1-s intervals at five sites in each community during midday. In summer, understory light during midday in shrub thickets was approximately 0.8% of above-canopy light, compared to 1.9% and 5.4% in pine and deciduous forests, respectively. During summer, PPFD was uncorrelated between sensors as close as 0.075 m in shrub thickets compared to 0.175 m and 0.900 m in pine and deciduous forests, respectively, indicating that sunflecks in shrub thickets were generally small compared to sunflecks in the two forests. Sunflecks in shrub thickets were generally short (all <30 s) and relatively low in intensity (<150 micromol photons x m(-2) x s(-1)) and contributed only 5% of understory light during midday. Sunflecks were longer (up to 6 minutes) and more intense (up to 350 micromol photons x m(-2) x s(-1)) in the two forest communities and Contributed 31% and 22% of understory light during midday in pine and deciduous forest, respectively. The combination of high LAI and relatively short-stature of M. cerifera shrub thickets produces a dense canopy that reduces both diffuse light and the occurrence of sunflecks. The lack of sunflecks may limit the number of microsites with a favorable light environment and contribute to the reduction in understory cover and diversity within the shrub thickets.

Shifts in litterfall and dominant nitrogen sources after expansion of shrub thickets.

Woody encroachment into herbaceous ecosystems is emerging as an important ecological response to global change. A primary concern is alterations in C and N cycling and associated variations across a variety of ecosystems. We quantified seasonal variation in litterfall and litter N concentration in Morella cerifera shrub thickets to assess changes in litterfall and associated N input after shrub expansion on an Atlantic coast barrier island. We also used the natural abundance of (15)N to estimate the proportion of litterfall N originating from symbiotic N fixation. Litterfall for shrub thickets ranged from 8,991 +/- 247 to 3,810 +/- 399 kg ha(-1) year(-1) and generally declined with increasing thicket age. Litterfall in three of the four thickets exceeded previous estimates of aboveground annual net primary production in adjacent grasslands by 300-400%. Leaf N concentration was also higher after shrub expansion and, coupled with low N resorption efficiency and high litterfall, resulted in a return of as much as 169 kg N ha(-1) year(-1) to the soil. We estimated that approximately 70% of N returned to the soil was from symbiotic N fixation resulting in an ecosystem input of between 37 and 118 kg ha(-1) year(-1) of atmospheric N depending on site. Considering the extensive cover of shrub thickets on Virginia barrier islands, N fixation by shrubs is likely the largest single source of N to the system. The shift from grassland to shrub thicket on barrier islands results in a substantial increase in litterfall and foliar N concentration that will likely have a major impact on the size and cycling of ecosystem C and N pools. Increasing C and N availability in these nutrient-poor soils is likely to permanently reduce cover of native grasses and alter community structure by favoring species with greater N requirements.

Leaf-area index and light attenuation in rapidly expanding shrub thickets.

There is increasing interest in the changes in ecosystem services that accompany the conversion of grasslands to shrub-dominated communities. Shrub structure and associated effects on the light environment may be especially important in affecting productivity and diversity. Leaf-area index (LAI) and understory light levels of Morella cerifera shrub thickets were assessed on Hog Island, Virginia, USA, at four sites along a soil chronosequence. LAI was estimated from annual leaf litter, with allometric models relating stem diameter to leaf area, with a portable integrating radiometer (LI-COR LAI-2000), and from photosynthetically active radiation (PAR) using the Beer-Lambert law. For the two youngest thickets, LAI estimates from leaf litter (approximately 10.0) approached levels often associated with tropical rain forest. Allometric models estimated LAI values at 9.8 and 12.5 for the same thickets. High LAI in thickets also results in high light attenuation. Light levels within thickets were as low as 0.7% of above-canopy PAR in the youngest thicket. These data suggest that M. cerifera shrub thickets have a very high potential for annual net primary production. Furthermore, extreme modification of the light environment, coupled with heavy shrub litter fall, may exclude potential competitors during thicket establishment and rapidly alter community structure and ecosystem function.

Lung injury linked to etanercept therapy.

Etanercept is the first anticytokine drug approved to treat rheumatoid arthritis. Side effects are infrequent, the most common being local skin reactions, headaches, and upper respiratory tract symptoms. We report the first case of lung injury that occurred while receiving this agent. Biopsy specimens of lung and skin lesions demonstrated noncaseating granulomas associated with a microscopic particulate. Withdrawal of etanercept achieved clinical stabilization, and the addition of prednisone resulted in rapid improvement.