Spread of networked populations is determined by the interplay between dispersal behavior and habitat configuration.

Predicting the spread of populations across fragmented habitats is vital if we are to manage their persistence in the long term. We applied network theory with a model and an experiment to show that spread rate is jointly defined by the configuration of habitat networks (i.e., the arrangement and length of connections between habitat fragments) and the movement behavior of individuals. We found that population spread rate in the model was well predicted by algebraic connectivity of the habitat network. A multigeneration experiment with the microarthropod Folsomia candida validated this model prediction. The realized habitat connectivity and spread rate were determined by the interaction between dispersal behavior and habitat configuration, such that the network configurations that facilitated the fastest spread changed depending on the shape of the species' dispersal kernel. Predicting the spread rate of populations in fragmented landscapes requires combining knowledge of species-specific dispersal kernels and the spatial configuration of habitat networks. This information can be used to design landscapes to manage the spread and persistence of species in fragmented habitats.

Rapid monitoring of ecological persistence.

Effective conservation of ecological communities requires accurate and up-to-date information about whether species are persisting or declining to extinction. The persistence of an ecological community is supported by its underlying network of species interactions. While the persistence of the network supporting the whole community is the most relevant scale for conservation, in practice, only small subsets of these networks can be monitored. There is therefore an urgent need to establish links between the small snapshots of data conservationists can collect, and the "big picture" conclusions about ecosystem health demanded by policymakers, scientists, and societies. Here, we show that the persistence of small subnetworks (motifs) in isolation-that is, their persistence when considered separately from the larger network of which they are a part-is a reliable probabilistic indicator of the persistence of the network as a whole. Our methods show that it is easier to detect if an ecological community is not persistent than if it is persistent, allowing for rapid detection of extinction risk in endangered systems. Our results also justify the common practice of predicting ecological persistence from incomplete surveys by simulating the population dynamics of sampled subnetworks. Empirically, we show that our theoretical predictions are supported by data on invaded networks in restored and unrestored areas, even in the presence of environmental variability. Our work suggests that coordinated action to aggregate information from incomplete sampling can provide a means to rapidly assess the persistence of entire ecological networks and the expected success of restoration strategies.

Including socioeconomic status reduces readmission penalties to safety-net hospitals.

OBJECTIVE: Medicare's Hospital Readmissions Reduction Program (HRRP) financially penalizes "excessive" postoperative readmissions. Concerned with creating a double standard for institutions treating a high percentage of economically vulnerable patients, Medicare elected to exclude socioeconomic status (SES) from its risk-adjustment model. However, recent evidence suggests that safety-net hospitals (SNHs) caring for many low-SES patients are disproportionately penalized under the HRRP. We sought to simulate the impact of including SES-sensitive models on HRRP penalties for hospitals performing lower extremity revascularization (LER). METHODS: This is a retrospective, cross-sectional analysis of national data on Medicare patients undergoing open or endovascular LER procedures between 2007 and 2009. We used hierarchical logistic regression to generate hospital risk-standardized 30-day readmission rates under Medicare's current model (adjusting for age, sex, comorbidities, and procedure type) compared with models that also adjust for SES. We estimated the likelihood of a penalty and penalty size for SNHs compared with non-SNHs under the current Medicare model and these SES-sensitive models. RESULTS: Our study population comprised 1708 hospitals performing 284,724 LER operations with an overall unadjusted readmission rate of 14.4% (standard deviation: 5.3%). Compared with the Centers for Medicare and Medicaid Services model, adjusting for SES would not change the proportion of SNHs penalized for excess readmissions (55.1% vs 53.4%, P = .101) but would reduce penalty amounts for 38% of SNHs compared with only 17% of non-SNHs, P < .001. CONCLUSIONS: For LER, changing national Medicare policy to including SES in readmission risk-adjustment models would reduce penalty amounts to SNHs, especially for those that are also teaching institutions. Making further strides toward reducing the national disparity between SNHs and non-SHNs on readmissions, performance measures require strategies beyond simply altering the risk-adjustment model to include SES.

Predictors of prolonged length of stay after elective carotid revascularization.

OBJECTIVE: Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. METHODS: Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. RESULTS: A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). CONCLUSIONS: A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Accuracy and consistency of publicly available Large Language Models as clinical decision support tools for the management of colon cancer.

BACKGROUND: Large Language Models (LLM; e.g., ChatGPT) may be used to assist clinicians and form the basis of future clinical decision support (CDS) for colon cancer. The objectives of this study were to (1) evaluate the response accuracy of two LLM-powered interfaces in identifying guideline-based care in simulated clinical scenarios and (2) define response variation between and within LLMs. METHODS: Clinical scenarios with "next steps in management" queries were developed based on National Comprehensive Cancer Network guidelines. Prompts were entered into OpenAI ChatGPT and Microsoft Copilot in independent sessions, yielding four responses per scenario. Responses were compared to clinician-developed responses and assessed for accuracy, consistency, and verbosity. RESULTS: Across 108 responses to 27 prompts, both platforms yielded completely correct responses to 36% of scenarios (n = 39). For ChatGPT, 39% (n = 21) were missing information and 24% (n = 14) contained inaccurate/misleading information. Copilot performed similarly, with 37% (n = 20) having missing information and 28% (n = 15) containing inaccurate/misleading information (p = 0.96). Clinician responses were significantly shorter (34 ± 15.5 words) than both ChatGPT (251 ± 86 words) and Copilot (271 ± 67 words; both p < 0.01). CONCLUSIONS: Publicly available LLM applications often provide verbose responses with vague or inaccurate information regarding colon cancer management. Significant optimization is required before use in formal CDS.

Connectivity mediates the spatial ecological impacts of a glyphosate-based herbicide in experimental metaecosystems.

Metacommunity ecology has shown that connectivity is important for the persistence of a species locally and across connected ecosystems, however we do not know if ecological effects in freshwater ecosystems exposed to biocides leaking from agriculture depend on metaecosystem connectivity. We experimentally replicated metaecosystems in the laboratory using gradostats as a model system. We tested the effects of connectivity, in terms of node distance from the pollutant-source, flow rate, and a glyphosate-based herbicide, on phytoplankton productivity, diversity and stability. Gradostats were composed of interconnected equally spaced nodes where resources and phytoplankton move directionally along a gradient of increasing distance from the source of the polluting herbicide. We hypothesised that ecological effects would be stronger in the node situated closer to the point of herbicide input, but that flow would suppress phytoplankton populations in distant nodes. Overall, RoundUp impacted phytoplankton productivity and stability by reducing algal biomass and abundances. This occurred especially in the node closest to the diluted herbicide point-source and under high flow, where species abundances were heavily suppressed by the effects of the rapidly flowing herbicide. At low flow on the other hand, distant nodes where buffered from the effects of the slow-moving herbicide. No differences in beta and gamma diversity among replicate metaecosystems was found; however, a significant loss of alpha diversity in all metaecosystems occurred through time until the end of the experiment. Together, these results point to the importance of considering aquatic connectivity in management plans for monitoring and mitigating unintended ecological consequences of agrochemical runoff.

Generalism drives abundance: A computational causal discovery approach.

A ubiquitous pattern in ecological systems is that more abundant species tend to be more generalist; that is, they interact with more species or can occur in wider range of habitats. However, there is no consensus on whether generalism drives abundance (a selection process) or abundance drives generalism (a drift process). As it is difficult to conduct direct experiments to solve this chicken-and-egg dilemma, previous studies have used a causal discovery method based on formal logic and have found that abundance drives generalism. Here, we refine this method by correcting its bias regarding skewed distributions, and employ two other independent causal discovery methods based on nonparametric regression and on information theory, respectively. Contrary to previous work, all three independent methods strongly indicate that generalism drives abundance when applied to datasets on plant-hummingbird communities and reef fishes. Furthermore, we find that selection processes are more important than drift processes in structuring multispecies systems when the environment is variable. Our results showcase the power of the computational causal discovery approach to aid ecological research.

Linking the influence and dependence of people on biodiversity across scales.

Biodiversity enhances many of nature's benefits to people, including the regulation of climate and the production of wood in forests, livestock forage in grasslands and fish in aquatic ecosystems. Yet people are now driving the sixth mass extinction event in Earth's history. Human dependence and influence on biodiversity have mainly been studied separately and at contrasting scales of space and time, but new multiscale knowledge is beginning to link these relationships. Biodiversity loss substantially diminishes several ecosystem services by altering ecosystem functioning and stability, especially at the large temporal and spatial scales that are most relevant for policy and conservation.

Metapopulation persistence can be inferred from incomplete surveys.

Habitat destruction and fragmentation are principal causes of species loss. While a local population might go extinct, a metapopulation-populations inhabiting habitat patches connected by dispersal-can persist regionally by recolonizing empty patches. To assess metapopulation persistence, two widely adopted indicators in conservation management are metapopulation capacity and patch importance. However, we face a fundamental limitation in that assessing metapopulation persistence requires that we survey or sample all the patches in a landscape: often these surveys are logistically challenging to conduct and repeat, which raises the question whether we can learn enough about the metapopulation persistence from an incomplete survey. Here, we provide a robust statistical approach to infer metapopulation capacity and patch importance by sampling a portion of all patches. We provided analytic arguments on why the metapopulation capacity and patch importance can be well predicted from sub-samples of habitat patches. Full-factorial simulations with more complex models corroborate our analytic predictions. We applied our model to an empirical metapopulation of mangrove hummingbirds (Amazilia boucardi). On the basis of our statistical framework, we provide some sampling suggestion for monitoring metapopulation persistence. Our approach allows for rapid and effective inference of metapopulation persistence from incomplete patch surveys.

Genotype diversity promotes the persistence of Daphnia populations exposed to severe copper stress.

When environmental stressors of high intensity are sustained for long periods of time, populations face high probabilities of being extirpated. However, depending on the intensity of the stressor, large populations with sufficient genetic diversity may persist. We report the results of an experiment that tracked the persistence of Daphnia populations exposed to copper contamination. We assessed whether genotypic diversity reduced the risk of extinction. We created monoclonal and multiclonal populations and monitored their population sizes during a 32-week experiment. Cu was applied at a sub-lethal concentration and then increased every week until the population sizes dropped to about 10% of the carrying capacity (Cu at 180 µg/L). The concentration was then increased up to 186 µg/L and held stable until the end of the experiment. A survival analysis showed that clonal diversity extended the persistence of Daphnia populations, but copper contamination caused a substantial genetic erosion followed by population extirpation. However, some Cu-treated populations, mostly multiclonal, showed U-shaped patterns of growth consistent with evolutionary rescue but these did not lead to lasting population recovery. These results highlight the importance of genetic variation for population persistence, but they also show how quickly it can be lost in contaminated environments.

Impact of Time Restricted Feeding on Markers of Cardiometabolic Health and Oxidative Stress in Resistance-Trained Firefighters.

ABSTRACT: McAllister, MJ, Gonzalez, AE, and Waldman, HS. Impact of time restricted feeding on markers of cardiometabolic health and oxidative stress in resistance-trained firefighters. J Strength Cond Res 36(9): 2515-2522, 2022-Firefighters are often exposed to numerous occupational stressors that cause inflammation, oxidative stress (OS), and elevated risk for developing cardiometabolic disease. Time-restricted feeding (TRF) has been shown to result in favorable changes in markers of inflammation and cardiometabolic health. This study investigated the impact of a 6-week TRF intervention (14:10; fasting:feeding) in resistance-trained firefighters. Blood was analyzed for several markers of inflammation, OS, and cardiometabolic health: insulin, ghrelin, leptin, glucagon, adiponectin, resistin, advanced glycated end products (AGE), advanced oxidation protein products, total nitrite-nitrate levels, tumor necrosis factor-α, interleukin (IL)-6, IL-8, IL-10, as well as glucose and lipid levels. A graded exercise test was also conducted before and after the TRF intervention, and substrate oxidation rates were calculated and compared before and after the intervention. Comparisons pre and post TRF were determined with dependent t -tests. Time-restricted feeding resulted in significant reductions in advanced oxidation protein products (∼31%) and AGEs (∼25%); however, no other changes were found. These findings suggest that TRF may be a nutrition intervention aimed at improving some select markers of cardiometabolic health in firefighters, namely, by the reductions in advanced oxidation protein products and AGEs.

Virtual Reality Based Active Shooter Training Drill Increases Salivary and Subjective Markers of Stress.

Law enforcement personnel are required to respond to a variety of dangerous, potentially life-threatening high stress scenarios. Virtual reality (VR)-based training has been shown to attenuate stress responses; however, little is known about the acute stress response from VR exposure. This study examined the impact of participating in a VR-based active shooter training drill (ASD) on markers of physiological stress as well as potential differences in men and women. To examine the impact of participation in a ~50 sec VR-based ASD, 29 subjects (n = 29; 17 males, 12 females) participated in a quasi-experimental single group design. Saliva samples were collected and analyzed from 27 of the 29 subjects a total of four times 1) 30-min prior to, 2) 5-min prior to, 3) 5-min after, and 4) 30-min after the ASD and analyzed for α-amylase (AA) activity and concentrations of secretory immunoglobulin-A (SIgA), cortisol (CORT), and uric acid (UA). Participation in the ASD resulted in a significant (p < 0.05) increase in salivary stress markers AA and SIgA. In addition, lower concentrations of CORT and UA were found in women compared to men. These findings have implications for law enforcement and/or military personnel that may seek to implement a VR-based training into their training regimen. Future studies should investigate the impact of longitudinal participation in ASD interventions to determine if this is an effective training method to reduce stress responses to real life active shooter training drills.

Refining analyses of existing data sets is valuable for macrogenetics: a response to Paz-Vinas, Jensen et al., (2021).

Paz-Vinas, Jensen et al. (2021) comment on data and methodological limits of Millette, Fugère, Debyser et al. (2020)-some affect a small proportion of our data sets and analyses and others need to be tackled more generally. These points do not refute our main conclusion of no strong signal of human impacts on COI variation globally.

Landscape modification and nutrient-driven instability at a distance.

Almost 50 years ago, Michael Rosenzweig pointed out that nutrient addition can destabilise food webs, leading to loss of species and reduced ecosystem function through the paradox of enrichment. Around the same time, David Tilman demonstrated that increased nutrient loading would also be expected to cause competitive exclusion leading to deleterious changes in food web diversity. While both concepts have greatly illuminated general diversity-stability theory, we currently lack a coherent framework to predict how nutrients influence food web stability across a landscape. This is a vitally important gap in our understanding, given mounting evidence of serious ecological disruption arising from anthropogenic displacement of resources and organisms. Here, we combine contemporary theory on food webs and meta-ecosystems to show that nutrient additions are indeed expected to drive loss in stability and function in human-impacted regions. Our models suggest that destabilisation is more likely to be caused by the complete loss of an equilibrium due to edible plant species being competitively excluded. In highly modified landscapes, spatial nutrient transport theory suggests that such instabilities can be amplified over vast distances from the sites of nutrient addition. Consistent with this theoretical synthesis, the empirical frequency of these distant propagating ecosystem imbalances appears to be growing. This synthesis of theory and empirical data suggests that human modification of the Earth is strongly connecting distantly separated ecosystems, causing rapid, expansive and costly nutrient-driven instabilities over vast areas of the planet. Similar to existing food web theory, the corollary to this spatial nutrient theory is that slowing down spatial nutrient pathways can be a potent means of stabilising degraded ecosystems.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Zone I Balloon Occlusion Time Affects Spinal Cord Injury in the Nonhuman Primate Model.

OBJECTIVES: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used clinically to limit torso bleeding and restore central perfusion. The objective of this study was to determine the sequelae of prolonged REBOA in a nonhuman primate animal model. SUMMARY BACKGROUND DATA: Prolonged duration of REBOA is associated with adverse clinical outcomes. Threshold occlusion values tied to relative risk have yet to be determined. METHODS: Juvenile baboons were subjected to 40% to 55% total blood volume hemorrhage to achieve profound hypotension and shock. Zone I REBOA was performed for 60 minutes to assess acute injury and survival at 4 hours (group 1; n = 7). Post-REBOA 10-day survival and complications were then compared between 60 minutes (group 2; n = 8) and 30 minutes (group 3; n = 6) REBOA animals. RESULTS: Overall survival was 20/21 (95%). IL-6 and IL-8 were elevated at 1 and 4 hours in group 1 (P = 0.005; P = 0.001). Comparing 60-minute REBOA with 30-minute REBOA, there was (1) hypertension compared with normotension (P = 0.005), (2) increased base deficit (P = 0.003), (3) elevated Troponin I (P = 0.04), and histological evidence of kidney injury (P = 0.004). In addition, group 2 demonstrated paralysis with histopathologic changes of spinal cord ischemia (SCI) in 4/8 (50%), with no SCI in group 3 (P = 0.033). CONCLUSIONS: REBOA limits mortality in the primate model of severe hemorrhagic shock. However, unopposed balloon inflation in the distal thoracic aorta for 60 minutes results in high rates of spinal cord ischemia, an effect mitigated by limiting balloon inflation to 30 minutes.

Scaling up biodiversity-ecosystem functioning relationships: the role of environmental heterogeneity in space and time.

The biodiversity and ecosystem functioning (BEF) relationship is expected to be scale-dependent. The autocorrelation of environmental heterogeneity is hypothesized to explain this scale dependence because it influences how quickly biodiversity accumulates over space or time. However, this link has yet to be demonstrated in a formal model. Here, we use a Lotka-Volterra competition model to simulate community dynamics when environmental conditions vary across either space or time. Species differ in their optimal environmental conditions, which results in turnover in community composition. We vary biodiversity by modelling communities with different sized regional species pools and ask how the amount of biomass per unit area depends on the number of species present, and the spatial or temporal scale at which it is measured. We find that more biodiversity is required to maintain functioning at larger temporal and spatial scales. The number of species required increases quickly when environmental autocorrelation is low, and slowly when autocorrelation is high. Both spatial and temporal environmental heterogeneity lead to scale dependence in BEF, but autocorrelation has larger impacts when environmental change is temporal. These findings show how the biodiversity required to maintain functioning is expected to increase over space and time.

Grand challenges in biodiversity-ecosystem functioning research in the era of science-policy platforms require explicit consideration of feedbacks.

Feedbacks are an essential feature of resilient socio-economic systems, yet the feedbacks between biodiversity, ecosystem services and human wellbeing are not fully accounted for in global policy efforts that consider future scenarios for human activities and their consequences for nature. Failure to integrate feedbacks in our knowledge frameworks exacerbates uncertainty in future projections and potentially prevents us from realizing the full benefits of actions we can take to enhance sustainability. We identify six scientific research challenges that, if addressed, could allow future policy, conservation and monitoring efforts to quantitatively account for ecosystem and societal consequences of biodiversity change. Placing feedbacks prominently in our frameworks would lead to (i) coordinated observation of biodiversity change, ecosystem functions and human actions, (ii) joint experiment and observation programmes, (iii) more effective use of emerging technologies in biodiversity science and policy, and (iv) a more inclusive and integrated global community of biodiversity observers. To meet these challenges, we outline a five-point action plan for collaboration and connection among scientists and policymakers that emphasizes diversity, inclusion and open access. Efforts to protect biodiversity require the best possible scientific understanding of human activities, biodiversity trends, ecosystem functions and-critically-the feedbacks among them.

Resistance, resilience, and functional redundancy of freshwater bacterioplankton communities facing a gradient of agricultural stressors in a mesocosm experiment.

Agricultural pollution with fertilizers and pesticides is a common disturbance to freshwater biodiversity. Bacterioplankton communities are at the base of aquatic food webs, but their responses to these potentially interacting stressors are rarely explored. To test the extent of resistance and resilience in bacterioplankton communities faced with agricultural stressors, we exposed freshwater mesocosms to single and combined gradients of two commonly used pesticides: the herbicide glyphosate (0-15 mg/L) and the neonicotinoid insecticide imidacloprid (0-60 µg/L), in high or low nutrient backgrounds. Over the 43-day experiment, we tracked variation in bacterial density with flow cytometry, carbon substrate use with Biolog EcoPlates, and taxonomic diversity and composition with environmental 16S rRNA gene amplicon sequencing. We show that only glyphosate (at the highest dose, 15 mg/L), but not imidacloprid, nutrients, or their interactions measurably changed community structure, favouring members of the Proteobacteria including the genus Agrobacterium. However, no change in carbon substrate use was detected throughout, suggesting functional redundancy despite taxonomic changes. We further show that communities are resilient at broad, but not fine taxonomic levels: 24 days after glyphosate application the precise amplicon sequence variants do not return, and tend to be replaced by phylogenetically close taxa. We conclude that high doses of glyphosate - but still within commonly acceptable regulatory guidelines - alter freshwater bacterioplankton by favouring a subset of higher taxonomic units (i.e., genus to phylum) that transiently thrive in the presence of glyphosate. Longer-term impacts of glyphosate at finer taxonomic resolution merit further investigation.

Understanding and finding opportunities for inclusive mentorship and sponsorships in vascular surgery.

Deliberate efforts are needed to address the lack of diversity in the vascular surgery workforce and to correct the current scarcity of diversity in vascular surgery leadership. Effective mentorship and sponsorship are crucial for success in academic surgery. In the present report, we have explained the importance of mentorship and sponsorship relationships for surgeons historically underrepresented in medicine, discussed the unique challenges faced by them in academic surgery, and provided a practical framework for fostering intentional and thoughtful mentor and sponsor relationships to nurture their careers.

Emergency Department Utilization and Readmissions Following Major Surgery: A Retrospective Study of Medicare Data.

BACKGROUND: Reliable strategies for reducing postoperative readmissions remain elusive. As the emergency department (ED) is a frequent source of post-operative admissions, we investigated whether hospitals with high readmission rates also have high rates of post-discharge ED visits and high rates of readmission once an ED visit occurs. METHODS: We conducted a retrospective analysis of 1,947,621 Medicare beneficiaries undergoing 1 of 5 common procedures in 2,894 hospitals between 2008 and 2011. We stratified hospitals into quintiles based on risk-standardized, 30-day post-discharge readmission rates (RSRR) and then compared rates of post-discharge ED visits, proportion readmitted from the ED, and readmissions within 7 days of ED discharge across these quintiles. RESULTS: RSRR varied widely across extremes of hospital quintiles (3.9% to 17.5%). Hospitals with either very low or very high RSRR had modest differences in rates of ED visits (12.4% versus 14.6%). In contrast, the proportion readmitted from the ED was nearly 3 times greater in Hospitals with very high RSRR compared with those with very low RSRR (12% versus 32.2%). These findings were consistent across all procedures. Importantly, hospitals with a low proportion readmitted from the ED did not exhibit an increased rate of readmission within 7 days of ED discharge. CONCLUSIONS: Although hospitals experience similar rates of ED visits following major surgery, some EDs and their affiliated surgeons and health system may deliver care preventing readmissions without an increased short-term risk of readmission following ED discharge. Reducing 30-day readmissions requires greater attention to the coordination of care delivered in the ED.