Long-Term Alpine Plant Responses to Global Change Drivers Depend on Functional Traits.

Forecasting plant responses under global change is a critical but challenging endeavour. Despite seemingly idiosyncratic responses of species to global change, greater generalisation of 'winners' and 'losers' may emerge from considering how species functional traits influence responses and how these responses scale to the community level. Here, we synthesised six long-term global change experiments combined with locally measured functional traits. We quantified the change in abundance and probability of establishment through time for 70 alpine plant species and then assessed if leaf and stature traits were predictive of species and community responses across nitrogen addition, snow addition and warming treatments. Overall, we found that plants with more resource-acquisitive trait strategies increased in abundance but each global change factor was related to different functional strategies. Nitrogen addition favoured species with lower leaf nitrogen, snow addition favoured species with cheaply constructed leaves and warming showed few consistent trends. Community-weighted mean changes in trait values in response to nitrogen addition, snow addition and warming were often different from species-specific trait effects on abundance and establishment, reflecting in part the responses and traits of dominant species. Together, these results highlight that the effects of traits can differ by scale and response of interest.

Predictors of 1-year mortality following discharge from the surgical intensive care unit after sepsis.

BACKGROUND: Postsepsis syndrome is associated with significant long-term mortality. The objective of this study was to determine predictors of mortality within 1 year of discharge from the surgical intensive care unit. METHODS: We retrospectively reviewed patients admitted to a surgical intensive care unit with sepsis (sequential organ failure assessment score ≥2, 2011-2022). Those who died within 1 year from discharge (n = 171) were compared to survivors (n = 639). Baseline characteristics, sepsis presentation, and hospitalization data were compared. A multiple logistic regression was performed to determine predictors of 1-year mortality after discharge. RESULTS: Compared with survivors, those who died were older, less likely to be transferred from another institution (35% vs 46%, P = .003), had more metastatic cancer (9% vs 1%, P < .01), or stage III + chronic kidney disease (16% vs 7%, P < .01). Admission sequential organ failure assessment score, lactate, and vasopressor use were comparable. The 1-year mortality cohort exhibited increased respiratory (15% vs 9%) and abdominal (66% vs 54%) infections (P < .01), median length of stay (29 vs 19, P < .005), renal failure (14% vs 9%, P = .048), and dependent discharge. Adjusted predictors of death included age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02-1.05), metastatic cancer (OR 8.0, 95% CI 2.6-25), chronic kidney disease (OR 2.8, 95% CI 1.4-5.6), length of stay (OR 1.02, 95% CI 1.0-1.03), and dependent discharge. A length of stay in the top quartile (>32 days) was associated with a 3-fold increase in postdischarge mortality compared with the lowest quartile (<10 days). CONCLUSION: We identified independent predictors of postdischarge mortality following sepsis, including age, length of stay, dependent discharge, and stage III + chronic kidney disease. These data can identify at-risk patients who can be targeted for closer follow-up.

The effects of socioeconomic status on complex ventral hernia repair operative decision-making and outcomes.

BACKGROUND: Patients from low socioeconomic backgrounds have greater rates of morbidity and mortality across disease processes. The Distressed Communities Index identified several socioeconomic components that were used to create a Distressed Communities Index score for every ZIP code, then broken into quintiles from prosperous to distressed. We aimed to explore whether socioeconomic distress as defined by the Distressed Communities Index affects the outcome of complex ventral hernia repair in the elderly population. METHODS: Retrospective analysis was performed using the Abdominal Core Health Collaborative data. Included were adults aged 65+ years undergoing elective complex ventral hernia repair from 2013 to 2021. Primary outcomes were postoperative outcomes and composite hernia recurrence by Distressed Communities Index quintile. The Cox proportional hazards model was used for composite recurrence, and logistic regression was used for postoperative outcomes. RESULTS: A total of 4,172 patients were included. Patients in distressed communities were more likely to identify as female or racial minority and had greater body mass index and American Society of Anesthesiologists class. Lower Distressed Communities Index quintile was associated with larger hernia (P = .012), open repair (P = .019), and 30-day complication (P = .05). There was no association between time to recurrence and Distressed Communities Index quintile (P = .24). After adjusted analysis, there was no significant difference for readmission, reoperation, recurrence, and complications. CONCLUSION: Patients from more distressed communities presented in worse clinical status with larger hernias. This likely contributed to greater rates of open repair and complications. However, when adjusted for these variables, outcomes were similar across Distressed Communities Index quintile. This supports the efficacy of complex hernia repair across socioeconomic classes.

Gender-Based Variations in Medicare Reimbursements Among Different Surgical Subspecialties.

Importance: Gender inequities and limited representation are an obstacle to surgical workforce diversification. There has been limited examination of gender-based disparities in billing practices among surgeons. Objective: To evaluate variations in practice metrics and billing practices among female and male surgeons and identify factors associated with gender disparities in Medicare reimbursements. Design, Setting, and Participants: This retrospective cross-sectional study used publicly available Medicare Fee-for-Service Provider Utilization and Payment data from January to December 31, 2021, to identify demographics, annual services provided, and financial payments and charges for general surgeons, surgical oncologists, and colorectal surgeons. Data were analyzed from November 2023 to February 2024. Exposure: The primary exposure of interest was surgeon gender (ie, female or male). Main Outcomes and Measures: The annual total submitted charges and payments submitted in 2021 by female and male surgeons were assessed. Additionally, the total number and types of services provided each year and the number of beneficiaries treated were examined. Multivariable linear regression models were used to evaluate the association of surgeon gender with payments, number of services, and beneficiaries. Results: A total of 20 549 general surgeons (5036 [24.5%] female; 15 513 [75.5%] male), 1065 surgical oncologists (450 [42.3%] female; 615 [57.7%] male), and 1601 colorectal surgeons (432 [27.0%] female; 1169 [73.0%] male) were included. Across all surgical subspecialties, female surgeons billed fewer mean (SE) Medicare charges (general surgeons: 30.1% difference; $224 934.80 [$3846.97] vs $321 868.50 [$3933.57]; surgical oncologists: 27.5% difference; $277 901.70 [$22 857.37] vs $382 882.90 [$19 566.06]; colorectal surgeons: 21.7% difference; $274 091.70 [$10 468.48] vs $350 146.10 [$8741.66]; all P < .001) and received significantly lower mean (SE) reimbursements (general surgeons: 29.0% difference; $51 787.61 [$917.91] vs $72 903.12 [$890.35]; surgical oncologists: 23.6% difference; $57 945.18 [$3853.28] vs $75 778.22 [$2622.75]; colorectal surgeons: 24.5% difference; $63 117.01 [$2248.10] vs $83 598.53 [$1934.77]; all P < .001). On multivariable analysis, a reimbursement gap remained across all 3 surgical subspecialties (general surgeons: -$14 963.46 [95% CI, -$18 822.27 to -$11 104.64] [P < .001]; surgical oncologists: -$8354.69 [95% CI, -$15 018.12 to -$1691.25] [P = .01]; colorectal surgeons: -$4346.73 [95% CI, -$7660.15 to -$1033.32] [P = .01]). Conclusions and Relevance: In this cross-sectional study, there was considerable gender-based variation in practice patterns and reimbursement among different surgical subspecialties serving the Medicare population. Differences in mean payment per service were associated with variations in billing and coding strategies among female and male surgeons.

Biodiversity in changing environments: An external-driver internal-topology framework to guide intervention.

Accompanying the climate crisis is the more enigmatic biodiversity crisis. Rapid reorganization of biodiversity due to global environmental change has defied prediction and tested the basic tenets of conservation and restoration. Conceptual and practical innovation is needed to support decision making in the face of these unprecedented shifts. Critical questions include: How can we generalize biodiversity change at the community level? When are systems able to reorganize and maintain integrity, and when does abiotic change result in collapse or restructuring? How does this understanding provide a template to guide when and how to intervene in conservation and restoration? To this end, we frame changes in community organization as the modulation of external abiotic drivers on the internal topology of species interactions, using plant-plant interactions in terrestrial communities as a starting point. We then explore how this framing can help translate available data on species abundance and trait distributions to corresponding decisions in management. Given the expectation that community response and reorganization are highly complex, the external-driver internal-topology (EDIT) framework offers a way to capture general patterns of biodiversity that can help guide resilience and adaptation in changing environments.

Patient-Reported Outcome Measures Within a National Multispecialty Surgical Quality Improvement Program.

Importance: Patient-reported outcome measures (PROMs) are increasingly recognized for their ability to promote patient-centered care, but concerted health information technology (HIT)-enabled PROM implementations have yet to be achieved for national surgical quality improvement. Objective: To evaluate the feasibility of collecting PROMs within a national surgical quality improvement program. Design, Setting, and Participants: This was a pragmatic implementation cohort study conducted from February 2020 to March 2023. Hospitals in the US participating in the American College of Surgeons National Surgical Quality Improvement Program and their patients were included in this analysis. Exposures: Strategies to increase PROM collection rates were identified using the Institute for Healthcare Improvement (IHI) Framework for Spread and the Consolidated Framework for Implementation Research and operationalized with the IHI Model for Improvement's Plan-Do-Study-Act (PDSA) cycles. Main Outcomes and Measures: The primary goal was to accrue more than 30 hospitals and achieve collection rates of 30% or greater in the first 3 years. Logistic regression was used to identify hospital-level factors associated with achieving collection rates of 30% or greater and to identify patient-level factors associated with response to PROMs. Results: At project close, 65 hospitals administered PROMs to 130 365 patients (median [IQR] age, 60.1 [46.2-70.0] years; 77 369 female [59.4%]). Fifteen PDSA cycles were conducted to facilitate implementation, primarily targeting the Consolidated Framework for Implementation Research domains of Inner Setting (ie, HIT platform) and Individuals (ie, patients). The target collection rate was exceeded in quarter 3 (2022). Fifty-eight hospitals (89.2%) achieved collection rates of 30% or greater, and 9 (13.8%) achieved collection rates of 50% or greater. The median (IQR) maximum hospital-level collection rate was 40.7% (34.6%-46.7%). The greatest increases in collection rates occurred when both email and short-message service text messaging were used, communications to patients were personalized with their surgeon's and hospital's information, and the number of reminders increased from 2 to 5. No identifiable hospital characteristic was associated with achieving the target collection rate. Patient age and insurance status contributed to nonresponse. Conclusions and Relevance: Results of this cohort study suggest that the large-scale electronic collection of PROMs into a national multispecialty surgical registry was feasible. Findings suggest that HIT platform functionality and earning patient trust were the keys to success; although, iterative opportunities to increase collection rates and address nonresponse remain. Future work to drive continuous surgical quality improvement with PROMs are ongoing.

Laparoscopic vs robotic inguinal hernia repair: a comparison of learning curves and skill transference in general surgery residents.

BACKGROUND: There is no consensus on whether laparoscopic experience should be a prerequisite for robotic training. Further, there is limited information on skill transference between laparoscopic and robotic techniques. This study focused on the general surgery residents' learning curve and skill transference within the two minimally invasive platforms. METHODS: General surgery residents were observed during the performance of laparoscopic and robotic inguinal hernia repairs. The recorded data included objective measures (operative time, resident participation indicated by percent active time on console or laparoscopy relative to total case time, number of handoffs between the resident and attending), and subjective evaluations (preceptor and trainee assessments of operative performance) while controlling for case complexity, patient comorbidities, and residents' prior operative experience. Wilcoxon two-sample tests and Pearson Correlation coefficients were used for analysis. RESULTS: Twenty laparoscopic and forty-four robotic cases were observed. Mean operative times were 90 min for robotic and 95 min for laparoscopic cases (P = 0.4590). Residents' active participation time was 66% on the robotic platform and 37% for laparoscopic (P = < 0.0001). On average, hand-offs occurred 9.7 times during robotic cases and 6.3 times during laparoscopic cases (P = 0.0131). The mean number of cases per resident was 5.86 robotic and 1.67 laparoscopic (P = 0.0312). For robotic cases, there was a strong correlation between percent active resident participation and their prior robotic experience (r = 0.78) while there was a weaker correlation with prior laparoscopic experience (r = 0.47). On the other hand, prior robotic experience had minimal correlation with the percent active resident participation in laparoscopic cases (r = 0.12) and a weak correlation with prior laparoscopic experience (r = 0.37). CONCLUSION: The robotic platform may be a more effective teaching tool with a higher degree of entrustability indicated by the higher mean resident participation. We observed a greater degree of skill transference from laparoscopy to the robot, indicated by a higher degree of correlation between the resident's prior laparoscopic experience and the percent console time in robotic cases. There was minimal correlation between residents' prior robotic experience and their participation in laparoscopic cases. Our findings suggest that the learning curve for the robot may be shorter as prior robotic experience had a much stronger association with future robotic performance compared to the association observed in laparoscopy.

Programmatic quality measures: a new model to promote surgical quality.

Health care performance metrics are offered predominantly in terms of outcomes, processes, or structural components of health care delivery. However, measurement is limited by variability in data sources, definitions, and workarounds. The American College of Surgeons has recently developed a new type of performance metric known as a "programmatic measure". These metrics align structures, processes, and outcomes to better coordinate quality measurement with support of frontline care teams. In this multifaceted way, these measures differ from current "single" measures such as targeting surgical site infection. The thematic focus of these measures and alignment of structure-resource components to support processes and outcomes also sets these measures apart from contemporary composite measures. Importantly, structural elements of these measures reflect minimum resources required for patient care, addressing staffing and resource barriers felt by local institutions in addressing numerous existing quality metrics. These metrics will streamline quality reporting to improve care navigation for patients. Clinicians will find more appropriately aligned goals and responsibilities, resulting in increased teamwork and communication. These measures are designed to address the current burdens of overabundant metrics, priority misalignment, and low resources in a patient-centric fashion to better align health care quality and measurement.

SAGES White Paper on the importance of diversity in surgical leadership: creating the fundamentals of leadership development (FLD) curriculum.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. METHODS: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. RESULTS: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. CONCLUSION: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery.

Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: health equity update to standard operating procedure.

INTRODUCTION: The SAGES Guidelines Committee creates evidence-based clinical practice guidelines. Due to existing health disparities, recommendations made in these guidelines may have different impacts on different populations. The updates to our standard operating procedure described herein will allow us to produce well-designed guidelines that take these disparities into account and potentially reduce health inequities. METHODS: This paper outlines updates to the SAGES Guidelines Committee Standard Operating Procedure in order to incorporate issues of heath equity into our guideline development process with the goal of minimizing downstream health disparities. RESULTS: SAGES has developed an evidence-based, standardized approach to consider issues of health equity throughout the guideline development process to allow physicians to better counsel patients and make research recommendations to better address disparities. CONCLUSION: Societies that promote guidelines within their organization must make an intentional effort to prevent the widening of health disparities as a result of their recommendations. The updates to the Guidelines Committee Standard Operating Procedure will hopefully lead to increased attention to these disparities and provide specific recommendations to reduce them.

Obesity is associated with improved early survival but increased late mortality in surgical patients with Sepsis: A propensity matched analysis.

BACKGROUND: While obesity is a risk factor for postoperative complications, its impact following sepsis is unclear. The primary objective of this study was to evaluate the association between obesity and mortality following admission to the surgical intensive care unit (SICU) with sepsis. METHODS: We conducted a single center retrospective review of SICU patients grouped into obese (n = 766, body mass index ≥30 kg/m 2 ) and nonobese (n = 574; body mass index, 18-29.9 kg/m 2 ) cohorts. Applying 1:1 propensity matching for age, sex, comorbidities, sequential organ failure assessment, and transfer status, demographic data, comorbidities, and sepsis presentation were compared between groups. Primary outcomes included in-hospital and 90-day mortality, ICU length of stay, need for mechanical ventilation (IMV) and renal replacement therapy (RRT). p < 0.05 was considered significant. RESULTS: Obesity associates with higher median ICU length of stay (8.2 vs. 5.6, p < 0.001), need for IMV (76% vs. 67%, p = 0.001), ventilator days (5 vs. 4, p < 0.004), and RRT (23% vs. 12%, p < 0.001). In-hospital (29% vs. 18%, p < 0.0001) and 90-day mortality (34% vs. 24%, p = 0.0006) was higher for obese compared with nonobese groups. Obesity independently predicted need for IMV (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2-2.1), RRT (OR, 2.2; 95% CI, 1.5-3.1), in-hospital (OR, 2.1; 95% CI, 1.5-2.8), and 90-day mortality (HR, 1.4; 95% CI, 1.1-1.8), after adjusting for sequential organ failure assessment, age, sex, and comorbidities. Comparative survival analyses demonstrate a paradoxical early survival benefit for obese patients followed by a rapid decline after 7 days (logrank p = 0.0009). CONCLUSION: Obesity is an independent risk factor for 90-day mortality for surgical patients with sepsis, but its impact appeared later in hospitalization. Understanding differences in systemic responses between these cohorts may be important for optimizing critical care management. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Quality of life among older patients after elective ventral hernia repair: A retrospective review.

BACKGROUND: Ventral hernia repair is a common elective general surgery procedure among older patients, a population at greater risk of complications. Prior research has demonstrated improved quality of life in this population despite increased risk of complications. This study sought to assess the relationship between post-ventral hernia repair quality of life and patient frailty. We hypothesized that frail patients would report smaller gains in quality of life compared to the non-frail group. METHODS: The Abdominal Core Health Quality Collaborative was used to identify a cohort of patients 65 years of age or older undergoing elective ventral hernia repair from 2018 to 2022. Patients were categorized based on their modified frailty index scores as not frail/prefrail, frail, and severely frail. Quality of life was assessed using a patient-reported 12-item scale preoperatively, 30 days, 6 months, and 1 year postoperatively. RESULTS: A total of 3,479 patients were included: 30.93% non-frail, 47.17% frail, and 21.90% severely frail. Severely frail patients had lower quality of life scores at baseline (P = .001) but reported higher quality of life at both 30 days (1.24 points higher, 95% confidence interval (-1.51, 2.52), P = .010) and 6 months (0.92 points higher, 95% confidence interval (-2.29, 4.13), P = .005). Severely frail patients had higher rates of surgical site complications (P < .001) but no difference in 30-day readmissions. CONCLUSION: Our results found that frail patients reported the greatest increase in quality of life 1 year from baseline, showing that they, when selected appropriately, can gain equal benefits and have similar surgical outcomes as their non-frail counterparts.

Measuring Chief Resident Skill and Entrustment Progression in An Operative Coaching Program: Four Years' Experience.

OBJECTIVE: Operative coaching (OC) may facilitate improvement of surgery residents' competencies by optimizing learning and teaching. We investigated how residents' operative skills and prospective entrustment (PE) progress throughout the chief year in our OC program, how OC is perceived by participants, and how OC may facilitate learning and teaching. DESIGN, SETTING, AND PARTICIPANTS: This is a mixed-methods study conducted within the Ohio State University Wexner Medical Center General Surgery residency. Validated performance evaluations with procedural-specific skill, general skill (GS), step-specific guidance required (SSG) (an autonomy measure), and PE measures completed by chiefs, faculty coaches, and attending surgeons from 7/2018 to 6/2022 were reviewed. We also interviewed OC participants to understand their experience. Descriptive statistical and qualitative content analysis were applied. RESULTS: 441 evaluations from 147 OC cases completed by 22 chiefs, 5 faculty coaches, and 24 attendings were included. Overall, resident GS (p = 0.036), SSG (p = 0.023), and PE (p = 0.002) significantly improved throughout the year. PE significantly correlated (all p < 0.0001) with SSG (r = 0.73), followed by procedural-specific skill (r = 0.59), then GS (r = 0.57). On average, chiefs underestimated their surgical skills while attendings overestimated autonomy they permitted to residents. Chiefs, coaches, and attendings reached consensus on chiefs' PE upon graduation. Five graduated chiefs and 5 attendings were interviewed. Chiefs described OC as effective in improving their self-regulated learning and particularly valued 3 OC elements: neutral authentic feedback, third-party real-time observation, and actionable feedback. Attendings noted OC promoted their engagement in skills assessment and teaching. CONCLUSIONS: Our findings suggest chief residents' skills, autonomy, and PE progress steadily along their OC journey. Despite differences in residents', coaches', and attendings' perceptions of skill, measures of autonomy reliably correlate with entrustment. OC promotes resident learning, faculty teaching, and assessment of resident skills, autonomy, and PE in the OR.

Outcomes and quality of life of frail patients following elective ventral hernia repair: Retrospective review of a national hernia collaborative.

BACKGROUND: Ventral hernia repair (VHR) is one of the most common general surgery procedures among older adults but is often deferred due to a higher risk of complications. This study compares postoperative quality of life (QOL) and complications between frail and non-frail patients undergoing elective VHR. We hypothesized that frail patients would have higher complication rates and smaller gains in quality of life compared to non-frail patients. STUDY DESIGN: Patients 65 years of age and older, undergoing elective VHR between 2018 and 2022 were selected from the ACHQC (Abdominal Core Health Quality Collaborative) and grouped based on frailty scores obtained using the Modified Frailty Index (mFI-5). Logistic regression adjusting for hernia characteristics (size, recurrent, parastomal, incisional) were performed for 30-day outcomes including surgical site infections (SSI), surgical site occurrences (SSO), surgical site infections/occurrences requiring procedural intervention (SSOPI), and readmission. Multivariable analyses controlling for patient and procedure characteristics were performed comparing QOL scores (HerQLes scale, 0-100) at baseline, 30 days, 6 months and 1 year postoperatively. RESULTS: A total of 4888 patients were included, 29.17% non-frail, 47.87% frail, and 22.95% severely frail. On adjusted analysis, severely frail patients had higher odds of SSO (most commonly seroma formation) but no evidence of a difference in SSI, SSOPI, readmission or mortality. Severely frail patients had lower median QOL scores at baseline (48.3/100, IQR 26.1-71.7, p â€‹= â€‹0.001) but reported higher QOL scores at both 30-days (68.3/100, IQR 41.7-88.3, p â€‹= â€‹0.01) and 6-months (86.7/100, IQR 65.0-93.3, p â€‹= â€‹0.005). CONCLUSION: Severely frail patients reported similar increases in QOL and similar complications to their not frail counterparts. Our results demonstrate that appropriately selected older patients, even those who are severely frail, may benefit from elective VHR in the appropriate clinical circumstance.

Flowering time responses to warming drive reproductive fitness in a changing Arctic.

BACKGROUND AND AIMS: The Arctic is warming at an alarming rate, leading to earlier spring conditions and plant phenology. It is often unclear to what degree changes in reproductive fitness (flower, fruit, seed production) are a direct response to warming versus an indirect response through shifting phenology. This study aims to quantify the relative importance of these direct and indirect pathways and project the net effects of warming on plant phenology and reproductive fitness under current and future climate scenarios. METHODS: We used two long-term datasets on twelve tundra species in the Canadian Arctic as part of the International Tundra Experiment (ITEX). Phenology and reproductive fitness were recorded annually on tagged individual plants at both Daring Lake, Northwest Territories (64.87, -111.58) and Alexandra Fiord, Nunavut (78.83, -75.80). Plant species encompass a wide taxonomic diversity across a range of plant functional types with circumpolar/boreal distributions. We use Hierarchical Bayesian Structural Equation models to compare the direct and indirect effects of climate warming on phenology and reproductive fitness across species, sites and years. KEY RESULTS: We find that warming, both experimental and ambient, drives earlier flowering across species, which leads to higher numbers of flowers and fruits produced, reflecting directional phenotypic selection for earlier flowering phenology. Furthermore, this indirect effect of climate warming mediated through phenology was generally ~2-3x stronger than the direct effect of climate on reproductive fitness. Under future climate predictions, individual plants showed a ~2 to 4.5-fold increase in their reproductive fitness (flower counts) with advanced flowering phenology. CONCLUSIONS: Our results suggest that, on average, the benefits of early flowering, such as increased development time and subsequent enhanced reproductive fitness, may outweigh its risks. Overall, this work provides important insights into population-level consequences of phenological shifts in a warming Arctic over multi-decadal time scales.

Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias.

INTRODUCTION: Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown. METHODS: The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups. RESULTS: In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013). CONCLUSIONS: This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.

Area Deprivation Index Predicts Mortality for Critically Ill Surgical Patients With Sepsis.

Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients.