Rapid evolution of a family-diagnostic trait: artificial selection and correlated responses in wild radish, Raphanus raphanistrum.

The mechanisms underlying trait conservation over long evolutionary time scales are poorly known. These mechanisms fall into the two broad and nonmutually exclusive categories of constraint and selection. A variety of factors have been hypothesized to constrain trait evolution. Alternatively, selection can maintain similar trait values across many species if the causes of selection are also relatively conserved, while many sources of constraint may be overcome over longer periods of evolutionary divergence. An example of deep trait conservation is tetradynamy in the large family Brassicaceae, where the four medial stamens are longer than the two lateral stamens. Previous work has found selection to maintain this difference in lengths, which we call anther separation, in wild radish, Raphanus raphanistrum. Here, we test the constraint hypothesis using five generations of artificial selection to reduce anther separation in wild radish. We found a rapid linear response to this selection, with no evidence for depletion of genetic variation and correlated responses to this selection in only four of 15 other traits, suggesting a lack of strong constraint. Taken together, available evidence suggests that tetradynamy is likely to be conserved due to selection, but the function of this trait remains unclear.

Airborne! UAV delivery of blood products and medical logistics for combat zones.

BACKGROUND: Innovative solutions to resupply critical medical logistics and blood products may be required in future near-peer conflicts. Unmanned aerial vehicles (UAVs) are increasingly being used in austere environments and may be a viable platform for medical resupply and the transport of blood products. METHODS: A literature review on PubMed and Google Scholar up to March of 2022 yielded a total of 27 articles that were included in this narrative review. The objectives of this article are to discuss the current limitations of prehospital blood transfusion in military settings, discuss the current uses of UAVs for medical logistics, and highlight the ongoing research surrounding UAVs for blood product delivery. DISCUSSION: UAVs allow for the timely delivery of medical supplies in numerous settings and have been utilized for both military and civilian purposes. Investigations into the effects of aeromedical transportation on blood products have found minimal blood product degradation when appropriately thermoregulated and delivered in a manner that minimizes trauma. UAV delivery of blood products is now actively being explored by numerous entities around the globe. Current limitations surrounding the lack of high-quality safety data, engineering constraints over carrying capacity, storage capability, and distance traveled, as well as air space regulations persist. CONCLUSION: UAVs may offer a novel solution for the transport of medical supplies and blood products in a safe and timely manner for the forward-deployed setting. Further research on optimal UAV design, optimal delivery techniques, and blood product safety following transport should be explored prior to implementation.

Robotic colorectal surgery in the emergent diverticulitis setting: is it safe? A review of large national database.

BACKGROUND: As robotic colorectal surgery continues to advance in conjunction with improved recovery protocols, we began implementing robotic surgery (RS) as an option for emergent diverticulitis surgery. Our hospital system utilizes the Da Vinci Xi system, and staff are required to undergo training, making emergent colorectal surgery a feasible option. However, it is essential to determine the safety with reproducibility of our experiences. METHODS: A de-identified retrospective review was performed of Intuitive's national database which obtained data from 262 facilities from January 2018 through December 2021. This identified over 22,000 emergent colorectal surgeries. Of those, over 2500 were performed for diverticulitis in which 126 were RS, 446 laparoscopic surgery (LS), and 1952 open surgery (OS). Clinical outcome metrics including conversion rates, anastomotic leaks, intensive care unit (ICU) admissions, length of stay, mortality, and readmissions were obtained. The cohort was defined by patients who were seen in the emergency department (ED) with diverticulitis and proceeded to have a sigmoid colectomy within 24 h of ED arrival. RESULTS: RS was associated with increased operating time (RS 262, LS 207, OS 182 min), but data has shown many benefits of emergent RS compared to OS. We identified significant decreases in ICU admission rates (OS 19.0%, RS 9.5%, p = 0.01) and anastomotic leak rates (OS 4.4%, RS 0.8%, p = 0.04), with borderline improvement in overall length of stay (OS 9.9, RS 8.9 days, p = 0.05). When compared with LS, RS showed many comparable results. However, RS witnessed a statistically significant improvement in anastomotic leak rates (LS 4.5%, RS 0.8%, p = 0.04). Importantly, there was a striking difference in conversion rates to OS. LS converted over 28.7% of cases to OS, whereas RS only converted 7.9%, p = 0.000005. CONCLUSION: Given these findings, RS is another MIS tool that could be a safe and feasible option for the acute management of emergent diverticulitis.

Predictive Models of Genetic Redundancy in Arabidopsis thaliana.

Genetic redundancy refers to a situation where an individual with a loss-of-function mutation in one gene (single mutant) does not show an apparent phenotype until one or more paralogs are also knocked out (double/higher-order mutant). Previous studies have identified some characteristics common among redundant gene pairs, but a predictive model of genetic redundancy incorporating a wide variety of features derived from accumulating omics and mutant phenotype data is yet to be established. In addition, the relative importance of these features for genetic redundancy remains largely unclear. Here, we establish machine learning models for predicting whether a gene pair is likely redundant or not in the model plant Arabidopsis thaliana based on six feature categories: functional annotations, evolutionary conservation including duplication patterns and mechanisms, epigenetic marks, protein properties including posttranslational modifications, gene expression, and gene network properties. The definition of redundancy, data transformations, feature subsets, and machine learning algorithms used significantly affected model performance based on holdout, testing phenotype data. Among the most important features in predicting gene pairs as redundant were having a paralog(s) from recent duplication events, annotation as a transcription factor, downregulation during stress conditions, and having similar expression patterns under stress conditions. We also explored the potential reasons underlying mispredictions and limitations of our studies. This genetic redundancy model sheds light on characteristics that may contribute to long-term maintenance of paralogs, and will ultimately allow for more targeted generation of functionally informative double mutants, advancing functional genomic studies.

High-throughput measurement of plant fitness traits with an object detection method using Faster R-CNN.

Revealing the contributions of genes to plant phenotype is frequently challenging because loss-of-function effects may be subtle or masked by varying degrees of genetic redundancy. Such effects can potentially be detected by measuring plant fitness, which reflects the cumulative effects of genetic changes over the lifetime of a plant. However, fitness is challenging to measure accurately, particularly in species with high fecundity and relatively small propagule sizes such as Arabidopsis thaliana. An image segmentation-based method using the software ImageJ and an object detection-based method using the Faster Region-based Convolutional Neural Network (R-CNN) algorithm were used for measuring two Arabidopsis fitness traits: seed and fruit counts. The segmentation-based method was error-prone (correlation between true and predicted seed counts, r2 = 0.849) because seeds touching each other were undercounted. By contrast, the object detection-based algorithm yielded near perfect seed counts (r2 = 0.9996) and highly accurate fruit counts (r2 = 0.980). Comparing seed counts for wild-type and 12 mutant lines revealed fitness effects for three genes; fruit counts revealed the same effects for two genes. Our study provides analysis pipelines and models to facilitate the investigation of Arabidopsis fitness traits and demonstrates the importance of examining fitness traits when studying gene functions.

Machine Learning for Military Trauma: Novel Massive Transfusion Predictive Models in Combat Zones.

BACKGROUND: Damage control resuscitation has become the standard of care in military and civilian trauma. Early identification of blood product requirements may aid in optimizing the clinical decision-making process while improving trauma related outcomes. This study aimed to assess and compare multiple machine learning models for predicting patients at highest risk for massive transfusion on the battlefield. METHODS: Supervised machine learning approaches using logistic regression, support vector machine, neural network, and random forest techniques were used to create predictive models for massive transfusion using standard prehospital and arrival data points from the Department of Defense Trauma Registry, 2008-2016. Seventy percent of the population was used for model development and performance was validated using the remaining 30%. Models were tested for accuracy and compared by standard performance statistics. RESULTS: A total of 22,158 patients (97% male, 58% penetrating injury, median age 25-29 y/o, average Injury Severity Score 9, with an overall mortality of 3%) were included in the analysis. Massive transfusion was required by 7.4% of patients. Overall accuracy was found to be above 90% in all models tested. Following cross validation and model training, the random forest model outperformed the alternatively tested models for precision, recall, and area under the curve. CONCLUSION: Machine learning techniques may allow for more optimal and rapid identification of combat trauma patients at highest risk for massive transfusion. These powerful approaches may uncover novel correlations and help improve triage, activation of massive transfusion resources, and trauma-related outcomes. Further research seeking to optimize and apply these algorithms to trauma-centered research should be pursued.

Evolution of phenotypic plasticity: Genetic differentiation and additive genetic variation for induced plant defence in wild arugula Eruca sativa.

Phenotypic plasticity is the primary mechanism of organismal resilience to abiotic and biotic stress, and genetic differentiation in plasticity can evolve if stresses differ among populations. Inducible defence is a common form of adaptive phenotypic plasticity, and long-standing theory predicts that its evolution is shaped by costs of the defensive traits, costs of plasticity and a trade-off in allocation to constitutive versus induced traits. We used a common garden to study the evolution of defence in two native populations of wild arugula Eruca sativa (Brassicaceae) from contrasting desert and Mediterranean habitats that differ in attack by caterpillars and aphids. We report genetic differentiation and additive genetic variance for phenology, growth and three defensive traits (toxic glucosinolates, anti-nutritive protease inhibitors and physical trichome barriers) as well their inducibility in response to the plant hormone jasmonic acid. The two populations were strongly differentiated for plasticity in nearly all traits. There was little evidence for costs of defence or plasticity, but constitutive and induced traits showed a consistent additive genetic trade-off within each population for the three defensive traits. We conclude that these populations have evolutionarily diverged in inducible defence and retain ample potential for the future evolution of phenotypic plasticity in defence.

Optimal Prospective Predictors of Mortality in Austere Environments.

BACKGROUND: Prospective predictors of trauma-related outcomes have been validated to guide management in low-resource settings. The primary objective of this study was to determine the optimal prospective prediction method for mortality within combat and humanitarian trauma. MATERIALS AND METHODS: Retrospective review of the Department of Defense Trauma Registry from 2008 to 2016 was performed for adult patients. Areas under receiver operating characteristic curves (AUROCs) were calculated to assess the predictability of shock index (SI), reverse SI × Glasgow Coma Scale (rSIG), SI × Glasgow Coma Scale (SIG), Revised Trauma Score, and Trauma and Injury Severity Score (TRISS) on mortality at point of injury, arrival in emergency department (ED), and the difference in vital signs between those time points. RESULTS: A total of 22,218 patients were included. Overall, 97.1% were male, median age range 25-29 y, Injury Severity Score 9.4 ± 0.07, with predominantly penetrating injuries (58.1%), and mortality of 3.4%. ED vitals yielded higher predictability of mortality for all tests based on higher AUROCs. TRISS and rSIG demonstrated the highest AUROCs (0.955 and 0.923, respectively). The optimal cutoff value for rSIG was 14.1 (sensitivity 89% and specificity 87%). rSIG values <14.1 were significantly associated with mortality (P < 0.01; odds ratio = 5.901). CONCLUSIONS: Initial ED vital signs represented a better predictor of early mortality compared with point of injury vital signs for all predictive tools assessed. TRISS and rSIG proved to be most predictive of mortality. However, of the prospective tools assessed, rSIG may be optimal scoring tool because of its ease of calculation and its increased ability to predict mortality.

Self-compatibility is over-represented on islands.

Because establishing a new population often depends critically on finding mates, individuals capable of uniparental reproduction may have a colonization advantage. Accordingly, there should be an over-representation of colonizing species in which individuals can reproduce without a mate, particularly in isolated locales such as oceanic islands. Despite the intuitive appeal of this colonization filter hypothesis (known as Baker's law), more than six decades of analyses have yielded mixed findings. We assembled a dataset of island and mainland plant breeding systems, focusing on the presence or absence of self-incompatibility. Because this trait enforces outcrossing and is unlikely to re-evolve on short timescales if it is lost, breeding system is especially likely to reflect the colonization filter. We found significantly more self-compatible species on islands than mainlands across a sample of > 1500 species from three widely distributed flowering plant families (Asteraceae, Brassicaceae and Solanaceae). Overall, 66% of island species were self-compatible, compared with 41% of mainland species. Our results demonstrate that the presence or absence of self-incompatibility has strong explanatory power for plant geographical patterns. Island floras around the world thus reflect the role of a key reproductive trait in filtering potential colonizing species in these three plant families.

Consequences of Whole-Genome Triplication as Revealed by Comparative Genomic Analyses of the Wild Radish Raphanus raphanistrum and Three Other Brassicaceae Species.

Polyploidization events are frequent among flowering plants, and the duplicate genes produced via such events contribute significantly to plant evolution. We sequenced the genome of wild radish (Raphanus raphanistrum), a Brassicaceae species that experienced a whole-genome triplication event prior to diverging from Brassica rapa. Despite substantial gene gains in these two species compared with Arabidopsis thaliana and Arabidopsis lyrata, ∼70% of the orthologous groups experienced gene losses in R. raphanistrum and B. rapa, with most of the losses occurring prior to their divergence. The retained duplicates show substantial divergence in sequence and expression. Based on comparison of A. thaliana and R. raphanistrum ortholog floral expression levels, retained radish duplicates diverged primarily via maintenance of ancestral expression level in one copy and reduction of expression level in others. In addition, retained duplicates differed significantly from genes that reverted to singleton state in function, sequence composition, expression patterns, network connectivity, and rates of evolution. Using these properties, we established a statistical learning model for predicting whether a duplicate would be retained postpolyploidization. Overall, our study provides new insights into the processes of plant duplicate loss, retention, and functional divergence and highlights the need for further understanding factors controlling duplicate gene fate.

Effect of expanded variation in anther position on pollinator visitation to wild radish, Raphanus raphanistrum.

Background and Aims: Plant-pollinator interactions shape the evolution of flowers. Floral attraction and reward traits have often been shown to affect pollinator behaviour, but the possible effect of efficiency traits on visitation behaviour has rarely been addressed. Anther position, usually considered a trait that influences efficiency of pollen deposition on pollinators, was tested here for its effect on pollinator visitation rates and visit duration in flowers of wild radish, Raphanus raphanistrum . Methods: Artificial selection lines from two experiments that expanded the naturally occurring phenotypic variation in anther position were used. In one experiment, plant lines were selected either to increase or to decrease anther exsertion. The other experiment decreased anther dimorphism, which resulted in increased short stamen exsertion. The hypothesis was that increased exsertion would increase visitation of pollen foragers due to increased visual attraction. Another hypothesis was that exsertion of anthers above the corolla would interfere with nectar foragers and increase the duration of visit per flower. Key Results: In the exsertion selection experiment, increased exsertion of both short and long stamens resulted in an increased number of fly visits per plant, and in the dimorphism experiment bee visits increased with increased short stamen exsertion. The duration of visits of nectar feeders declined significantly with increasing long stamen exsertion, which was opposite to the hypothesis. Conclusions: Until now, anther position was considered to be an efficiency trait to enhance pollen uptake and deposition. Anther position in wild radish is shown here also to have an ecological significance in attracting pollen foragers. This study suggests an additional adaptive role for anther position beyond efficiency, and highlights the multiple ecological functions of floral traits in plant-pollinator interactions.

Floral function: effects of traits on pollinators, male and female pollination success, and female fitness across three species of milkweeds (Asclepias).

PREMISE OF THE STUDY: Central questions in plant reproductive ecology are whether the functions of floral traits in hermaphrodites create conflict between sexes that could slow evolution, and whether individual floral traits function in pollinator attraction, efficiency, or both. We studied how floral traits affect pollinator visitation and efficiency, and how they affect male and female function and female fitness within and across three Asclepias species that differ in floral morphology. METHODS: Using separate multiple regressions, we regressed pollen removal, deposition, and fruit number onto six floral traits. We also used path analyses integrating these variables with pollinator visitation data for two of the species to further explore floral function and its effects on fruit production. KEY RESULTS: Most traits affected male pollination success only, and these effects often differed between species. The exception was increased slit length, which increased pollinia insertion in two of the species. There were no interspecific differences in the effects of the traits on female pollination success. All traits except horn reach affected pollination efficiency in at least one species, and horn reach and two hood dimensions were the only traits to affect pollinator attraction, but in just one species. CONCLUSIONS: Traits tended to function in only one sex, and more traits affected function through pollinator efficiency than through attraction. There was no significant link between female pollination success and female fitness in any of the three species; this pattern is consistent with fruit production not being limited by pollen deposition.

Factors influencing the effect size distribution of adaptive substitutions.

The distribution of effect sizes of adaptive substitutions has been central to evolutionary biology since the modern synthesis. Early theory proposed that because large-effect mutations have negative pleiotropic consequences, only small-effect mutations contribute to adaptation. More recent theory suggested instead that large-effect mutations could be favoured when populations are far from their adaptive peak. Here we suggest that the distributions of effect sizes are expected to differ among study systems, reflecting the wide variation in evolutionary forces and ecological conditions experienced in nature. These include selection, mutation, genetic drift, gene flow, and other factors such as the degree of pleiotropy, the distance to the phenotypic optimum, whether the optimum is stable or moving, and whether new mutation or standing genetic variation provides the source of adaptive alleles. Our goal is to review how these factors might affect the distribution of effect sizes and to identify new research directions. Until more theory and empirical work is available, we feel that it is premature to make broad generalizations about the effect size distribution of adaptive substitutions important in nature.

The scope of Baker's law.

Baker's law refers to the tendency for species that establish on islands by long-distance dispersal to show an increased capacity for self-fertilization because of the advantage of self-compatibility when colonizing new habitat. Despite its intuitive appeal and broad empirical support, it has received substantial criticism over the years since it was proclaimed in the 1950s, not least because it seemed to be contradicted by the high frequency of dioecy on islands. Recent theoretical work has again questioned the generality and scope of Baker's law. Here, we attempt to discern where the idea is useful to apply and where it is not. We conclude that several of the perceived problems with Baker's law fall away when a narrower perspective is adopted on how it should be circumscribed. We emphasize that Baker's law should be read in terms of an enrichment of a capacity for uniparental reproduction in colonizing situations, rather than of high selfing rates. We suggest that Baker's law might be tested in four different contexts, which set the breadth of its scope: the colonization of oceanic islands, metapopulation dynamics with recurrent colonization, range expansions with recurrent colonization, and colonization through species invasions.

Quantifying nonadditive selection caused by indirect ecological effects.

In natural biological communities, species interact with many other species. Multiple species interactions can lead to indirect ecological effects that have important fitness consequences and can cause nonadditive patterns of natural selection. Given that indirect ecological effects are common in nature, nonadditive selection may also be quite common. As a result, quantifying nonadditive selection resulting from indirect ecological effects may be critical for understanding adaptation in natural communities composed of many interacting species. We describe how to quantify the relative strength of nonadditive selection resulting from indirect ecological effects compared to the strength of pairwise selection. We develop a clear method for testing for nonadditive selection caused by indirect ecological effects and consider how it might affect adaptation in multispecies communities. We use two case studies to illustrate how our method can be applied to empirical data sets. Our results suggest that nonadditive selection caused by indirect ecological effects may be common in nature. Our hope is that trait-based approaches, combined with multifactorial experiments, will result in more estimates of nonadditive selection that reveal the relative importance of indirect ecological effects for evolution in a community context.

How weeds emerge: a taxonomic and trait-based examination using United States data.

Weeds can cause great economic and ecological harm to ecosystems. Despite their importance, comparisons of the taxonomy and traits of successful weeds often focus on a few specific comparisons - for example, introduced versus native weeds. We used publicly available inventories of US plant species to make comprehensive comparisons of the factors that underlie weediness. We quantitatively examined taxonomy to determine if certain genera are overrepresented by introduced, weedy or herbicide-resistant species, and we compared phenotypic traits of weeds to those of nonweeds, whether introduced or native. We uncovered genera that have more weeds and introduced species than expected by chance and plant families that have more herbicide-resistant species than expected by chance. Certain traits, generally related to fast reproduction, were more likely to be associated with weedy plants regardless of species' origins. We also found stress tolerance traits associated with either native or introduced weeds compared with native or introduced nonweeds. Weeds and introduced species have significantly smaller genomes than nonweeds and native species. These results support trends for weedy plants reported from other floras, suggest that native and introduced weeds have different stress adaptations, and provide a comprehensive survey of trends across weeds within the USA.

Plasticity-mediated persistence and subsequent local adaptation in a global agricultural weed.

Phenotypic plasticity can alter traits that are crucial to population establishment in a new environment, before adaptation can occur. How often phenotypic plasticity enables subsequent adaptive evolution is unknown, and examples of the phenomenon are limited. We investigated the hypothesis of plasticity-mediated persistence as a means of colonization of agricultural fields in one of the world's worst weeds, Raphanus raphanistrum ssp. raphanistrum. Using non-weedy native populations of the same species and subspecies as a comparison, we tested for plasticity-mediated persistence in a growth chamber reciprocal transplant experiment. We identified traits with genetic differentiation between the weedy and native ecotypes as well as phenotypic plasticity between growth chamber environments. We found that most traits were both plastic and differentiated between ecotypes, with the majority plastic and differentiated in the same direction. This suggests that phenotypic plasticity may have enabled radish populations to colonize and then adapt to novel agricultural environments.

The Roles of Drift and Selection on Short Stamen Loss in Arabidopsis thaliana along an Elevational Gradient in the Spanish Pyrenees.

Traits that have lost function sometimes persist through evolutionary time. These traits may be maintained by a lack of standing genetic variation for the trait, if selection against the trait is weak relative to drift, or if they have a residual function. To determine the evolutionary processes shaping whether nonfunctional traits are retained or lost, we investigated short stamens in 16 populations of Arabidopsis thaliana along an elevational cline in the Spanish Pyrenees. We found a cline in short stamen number from retention of short stamens in high elevation populations to incomplete loss in low elevation populations. We did not find evidence that limited genetic variation constrains the loss of short stamens at high elevations nor evidence for divergent selection on short stamens between high and low elevations. Finally, we identified loci associated with short stamens in the Spanish Pyrenees that are different from loci associated with variation in short stamen number across latitudes from a previous study. Overall, we did not identify the evolutionary mechanisms maintaining an elevational cline in short stamen number but did identify different genetic loci underlying the variation in short stamen along similar phenotypic clines.

Strong evidence for positive and negative correlational selection revealed by recreating ancestral variation.

The study of adaptation helps explain biodiversity and predict future evolution. Yet the process of adaptation can be difficult to observe due to limited phenotypic variation in contemporary populations. Furthermore, the scarcity of male fitness estimates has made it difficult to both understand adaptation and evaluate sexual conflict hypotheses. We addressed both issues in our study of two anther position traits in wild radish (Raphanus raphanistrum): anther exsertion (long filament - corolla tube lengths) and anther separation (long - short filament lengths). These traits affect pollination efficiency and are particularly interesting due to the unusually high correlations among their component traits. We measured selection through male and female fitness on wild radish plants from populations artificially selected to recreate ancestral variation in each anther trait. We found little evidence for conflicts between male and female function. We found strong evidence for stabilizing selection on anther exsertion and disruptive selection on anther separation, indicating positive and negative correlational selection on the component traits. Intermediate levels of exsertion are likely an adaptation to best contact small bees. The function of anther separation is less clear, but future studies might investigate pollen placement on pollinators and compare species possessing multiple stamen types.

Impact of COVID on surgical case volume at military treatment facilities with surgical residencies.

INTRODUCTION: The Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) ("direct care"; DC) & off-base civilian facilities ("purchased care"; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies. METHODS: Retrospective review of 2017-2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets. RESULTS: 5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 - Q1 2020 vs Q3 2020 - Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID. DISCUSSION: Bariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.