Reduced fire severity offers near-term buffer to climate-driven declines in conifer resilience across the western United States.

Increasing fire severity and warmer, drier postfire conditions are making forests in the western United States (West) vulnerable to ecological transformation. Yet, the relative importance of and interactions between these drivers of forest change remain unresolved, particularly over upcoming decades. Here, we assess how the interactive impacts of changing climate and wildfire activity influenced conifer regeneration after 334 wildfires, using a dataset of postfire conifer regeneration from 10,230 field plots. Our findings highlight declining regeneration capacity across the West over the past four decades for the eight dominant conifer species studied. Postfire regeneration is sensitive to high-severity fire, which limits seed availability, and postfire climate, which influences seedling establishment. In the near-term, projected differences in recruitment probability between low- and high-severity fire scenarios were larger than projected climate change impacts for most species, suggesting that reductions in fire severity, and resultant impacts on seed availability, could partially offset expected climate-driven declines in postfire regeneration. Across 40 to 42% of the study area, we project postfire conifer regeneration to be likely following low-severity but not high-severity fire under future climate scenarios (2031 to 2050). However, increasingly warm, dry climate conditions are projected to eventually outweigh the influence of fire severity and seed availability. The percent of the study area considered unlikely to experience conifer regeneration, regardless of fire severity, increased from 5% in 1981 to 2000 to 26 to 31% by mid-century, highlighting a limited time window over which management actions that reduce fire severity may effectively support postfire conifer regeneration.

Functional composition outweighs taxonomic and functional diversity in maintaining ecosystem properties and processes of mangrove forests.

Biodiversity loss can have significant consequences for human well-being, as it can affect multiple ecosystem properties and processes (MEPP) that drive ecosystem services. However, a comprehensive understanding of the link between environmental factors, biodiversity, and MEPP remains elusive, especially in mangrove ecosystems that millions of people along tropical coastlines worldwide depend upon. Here, we collated a comprehensive dataset on forest inventory, plant traits, and environmental factors across 93 plots in the Sundarbans Reserved Forests, Bangladesh. The functional composition (FC) of leaf area showed a stronger positive association with MEPP, being determined by total biomass and productivity of the mangroves, sediment organic carbon, and ammonium, phosphorus, and potassium contents of the sediment, than species richness (SR) or functional diversity (FD). Further, FC mediated a strong negative association of sediment salinity, and a positive association of SR, with MEPP. The similar but opposite total associations of SR and sediment salinity with MEPP suggest that species-rich mangroves could offset the negative impacts of rising salinity on MEPP. When focusing on a single aspect of MEPP, both FD and FC mattered, with the FD of leaf area showing a strong association with mangrove productivity and sediment potassium content, while the FC of leaf litter nitrogen showed the strongest associations with sediment ammonium and phosphorus contents. Therefore, to sustain mangrove ecosystems as a reliable nature-based solution for climate change mitigation, conservation and (re-)establishment projects should prioritize regionally dominant species with high leaf area and nitrogen content, plus functionally different species to support the ecosystem processes and services provided by mangroves.

Consistent spatial scaling of high-severity wildfire can inform expected future patterns of burn severity.

Increasing wildfire activity in forests worldwide has driven urgency in understanding current and future fire regimes. Spatial patterns of area burned at high severity strongly shape forest resilience and constitute a key dimension of fire regimes, yet remain difficult to predict. To characterize the range of burn severity patterns expected within contemporary fire regimes, we quantified scaling relationships relating fire size to patterns of burn severity. Using 1615 fires occurring across the Northwest United States between 1985 and 2020, we evaluated scaling relationships within fire regimes and tested whether relationships vary across space and time. Patterns of high-severity fire demonstrate consistent scaling behaviour; as fire size increases, high-severity patches consistently increase in size and homogeneity. Scaling relationships did not differ substantially across space or time at the scales considered here, suggesting that as fire-size distributions potentially shift, stationarity in patch-size scaling can be used to infer future patterns of burn severity.

Incidence of Infection in Operatively Treated Distal Radius Fractures After Conversion From External to Internal Fixation.

PURPOSE: The purpose of this study was to report the incidence of infection after conversion from external fixation (EF) to internal fixation (IF) of distal radius fractures and to evaluate the relationship between infection and secondary variables, including time to conversion from EF to IF, internal hardware overlapping EF pin sites, and definitive fixation with a dorsal-spanning bridge plate. METHODS: A retrospective review was performed at 2 level 1 trauma centers including all patients aged ≥18 years from 2006 to 2019 with a distal radius fracture treated initially with EF followed by subsequent IF. The patients were excluded from analysis if they had <10 weeks of clinical follow-up, a history of prior distal radius surgery, or evidence of infection before EF to IF conversion. Patient demographic data, mechanism of injury, presence of hardware overlapping pin sites, and timing to definitive fixation were obtained from the medical records. Infection was defined as positive intraoperative cultures or documented return to the operating room for debridement after IF. RESULTS: A total of 64 fractures in 61 patients with a median age of 50 years (range, 18-75 years) were included. Infections developed in 6 patients (6 of 64 fractures). The incidence of infection was higher in patients with a time to conversion from EF to IF of >14 days (infection in 2 of 5 patients vs 4 of 59 patients). The incidence of infection was similar in patients with and without hardware overlapping EF pin sites (3 of 27 vs 3 of 37, respectively). CONCLUSIONS: Infections occurred in 6 of 64 distal radius fractures following conversion from EF to IF, and delay in conversion of >14 days was associated with an increased infection risk. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Corralling a black swan: natural range of variation in a forest landscape driven by rare, extreme events.

The natural range of variation (NRV) is an important reference for ecosystem management, but has been scarcely quantified for forest landscapes driven by infrequent, severe disturbances. Extreme events such as large, stand-replacing wildfires at multi-century intervals are typical for these regimes; however, data on their characteristics are inherently scarce, and, for land management, these events are commonly considered too large and unpredictable to integrate into planning efforts (the proverbial "Black Swan"). Here, we estimate the NRV of late-seral (mature/old-growth) and early-seral (post-disturbance, pre-canopy-closure) conditions in a forest landscape driven by episodic, large, stand-replacing wildfires: the Western Cascade Range of Washington, USA (2.7 million ha). These two seral stages are focal points for conservation and restoration objectives in many regions. Using a state-and-transition simulation approach incorporating uncertainty, we assess the degree to which NRV estimates differ under a broad range of literature-derived inputs regarding (1) overall fire rotations and (2) how fire area is distributed through time, as relatively frequent smaller events (less episodic), or fewer but larger events (more episodic). All combinations of literature-derived fire rotations and temporal distributions (i.e., "scenarios") indicate that the largest wildfire events (or episodes) burned up to 105 -106  ha. Under most scenarios, wildfire dynamics produced 5th-95th percentile ranges for late-seral forests of ~47-90% of the region (median 70%), with structurally complex early-seral conditions composing ~1-30% (median 6%). Fire rotation was the main determinant of NRV, but temporal distribution was also important, with more episodic (temporally clustered) fire yielding wider NRV. In smaller landscapes (20,000 ha; typical of conservation reserves and management districts), ranges were 0-100% because fires commonly exceeded the landscape size. Current conditions are outside the estimated NRV, with the majority of the region instead covered by dense mid-seral forests (i.e., a regional landscape with no historical analog). Broad consistency in NRV estimates among widely varied fire regime parameters suggests these ranges are likely relevant even under changing climatic conditions, both historical and future. These results indicate management-relevant NRV estimates can be derived for seral stages of interest in extreme-event landscapes, even when incorporating inherent uncertainties in disturbance regimes.

A Dedicated Quarterly Research Meeting Increases Resident Research Productivity.

BACKGROUND: Research is a vital component of a plastic surgery residency. Residents participating in research are better able to critically evaluate literature, allowing them to stay current throughout their careers. Programs benefit from increased research by increasing their academic reputation and attracting stronger applicants. To discuss ongoing research projects, foster collaboration, and encourage resident involvement, a quarterly research meeting was implemented within our division. We report the effectiveness of a dedicated division-wide quarterly research meeting in increasing the academic productivity of plastic surgery residents. MATERIALS AND METHODS: Beginning in 2015, the Division of Plastic Surgery at our institution implemented a dedicated quarterly research meeting. Academic productivity was assessed by the number of publications in peer-reviewed journals, oral presentations at national meetings, and oral presentations at regional meetings. We examined the change in productivity before and after the implementation of the quarterly meeting. Unpaired t-test was used to compare temporal differences. A direct temporal comparison was made between the 3 y of data before the implementation of the quarterly meetings and the 2 y of data after implementation. RESULTS: In the 2 y after the implementation of the research meeting, residents published significantly more often with an average of 2 peer-reviewed journal articles published per year per resident compared with 0.47 peer-reviewed publications in the 3 y before implementation (2 versus 0.47 publications per resident per year, P = 0.009). Residents were also more likely to present at national (0 versus 0.75 presentations per resident per year, P = 0.028) and regional meetings (0 versus 1 presentations per resident per year, P = 0.001). CONCLUSIONS: Implementation of a formal quarterly research meeting significantly improves resident research productivity. Residents demonstrated more publications and oral presentations. These results suggest that a more formal quarterly discussion of division-wide research can improve resident research productivity.

Spatial variability in tree regeneration after wildfire delays and dampens future bark beetle outbreaks.

Climate change is altering the frequency and severity of forest disturbances such as wildfires and bark beetle outbreaks, thereby increasing the potential for sequential disturbances to interact. Interactions can amplify or dampen disturbances, yet the direction and magnitude of future disturbance interactions are difficult to anticipate because underlying mechanisms remain poorly understood. We tested how variability in postfire forest development affects future susceptibility to bark beetle outbreaks, focusing on mountain pine beetle (Dendroctonus ponderosae) and Douglas-fir beetle (Dendroctonus pseudotsugae) in forests regenerating from the large high-severity fires that affected Yellowstone National Park in Wyoming in 1988. We combined extensive field data on postfire tree regeneration with a well-tested simulation model to assess susceptibility to bark beetle outbreaks over 130 y of stand development. Despite originating from the same fire event, among-stand variation in forest structure was very high and remained considerable for over a century. Thus, simulated emergence of stands susceptible to bark beetles was not temporally synchronized but was protracted by several decades, compared with stand development from spatially homogeneous regeneration. Furthermore, because of fire-mediated variability in forest structure, the habitat connectivity required to support broad-scale outbreaks and amplifying cross-scale feedbacks did not develop until well into the second century after the initial burn. We conclude that variability in tree regeneration after disturbance can dampen and delay future disturbance by breaking spatiotemporal synchrony on the landscape. This highlights the importance of fostering landscape variability in the context of ecosystem management given changing disturbance regimes.

Abdominal Contouring and Male Gender: Analysis of Complications Using the National Quality Improvement Program Database.

BACKGROUND: Males represent a significant portion of patients undergoing abdominal contouring. Despite this, there are few studies examining the implication of gender on complications. OBJECTIVE: The aim of this study was to examine the association between gender and early postoperative outcomes in patients undergoing abdominal contouring procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2006-2016) was queried to identify subjects undergoing panniculectomy or abdominoplasty. Minor and major complications were identified. Operative time and length of hospital stay were evaluated. A logistic regression model was used to examine associations between patient gender and adverse outcomes. RESULTS: Ten thousand four hundred seventy-three patients were identified. Of these, 4369 underwent abdominoplasties, and 6104 underwent panniculectomies. Males represented a higher percentage of the panniculectomy cohort (15.3% vs 9.2%). Males were older and generally had more comorbidities including diabetes, hypertension, chronic obstructive pulmonary disease, and elevated body mass index. Males also had a higher American Society of Anesthesiologists classification (P < 0.001). In the abdominoplasty cohort, male gender is an independent risk factor for any complication (odds ratio [OR], 1.3; confidence interval [CI], 1.16-1.45; P < 0.001) and major complications (OR, 1.52; CI, 1.01-2.29; P = 0.043). In the panniculectomy cohort, male gender is also an independent risk factor for any complication (OR, 1.47; CI, 1.24-1.75; P < 0.001) and major complications (OR, 1.43; CI, 1.12-1.83; P < 0.001). Males also had a significantly longer operative times in this cohort (171.3 vs 157.5 minutes; P < 0.001). CONCLUSIONS: Male gender is independently associated with minor and major complications in these patient populations. With this knowledge, plastic surgeons may be better able to identify higher-risk individuals and educate patients on their risk profile.

Variables associated with 30-day postoperative complications in lower extremity free flap reconstruction identified in the ACS-NSQIP database.

BACKGROUND: Lower extremity free flaps are a common way to treat both traumatic and oncologic lower extremity wounds. These patients often suffer postoperative complications. We sought to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify variables associated with postoperative complications. METHODS: Patients who had free flap procedure and a primary diagnosis code for lower extremity pathology were identified in the NSQIP database from 2006 to 2017. NSQIP includes data on preoperative, intraoperative, and postoperative variables, including information up to 30 postoperative days. Current procedural terminology (CPT) codes for free flaps and international classification of diseases (ICD) 9 and 10 codes for lower extremity pathology were used for our cohort. We examined overall and major complication rates. Major complications were defined as reoperation, readmission, organ space infection, or death. Univariate and multivariate analyses were used to identify associations with complications. RESULTS: Four hundred and eighty-three patients underwent lower extremity free flaps. Overall complication rate was 31.6% and major complication rate was 14.9%. Prolonged operative time (OR = 2.81, CI:1.76-4.48, p < .001), preoperative steroid use (OR = 3.04, CI:1.12-8.29, p = .030), and preoperative anemia (OR = 4.10, CI:2.00-8.41, p < .001) were independently associated with any complication. Diabetes (OR = 2.56, CI:1.24-5.29, p = .011) and prolonged operative time (OR = 3.75, CI:2.17-6.47, p < .001) were independently associated with major complications. CONCLUSIONS: In lower extremity flap reconstruction, associations with overall complications include prolonged operative time, steroid use, and anemia. Associations with major complications included diabetes and prolonged operative time. These associations can be used to guide interventions on patients identified to have greater risk of complications.

Evidence for declining forest resilience to wildfires under climate change.

Forest resilience to climate change is a global concern given the potential effects of increased disturbance activity, warming temperatures and increased moisture stress on plants. We used a multi-regional dataset of 1485 sites across 52 wildfires from the US Rocky Mountains to ask if and how changing climate over the last several decades impacted post-fire tree regeneration, a key indicator of forest resilience. Results highlight significant decreases in tree regeneration in the 21st century. Annual moisture deficits were significantly greater from 2000 to 2015 as compared to 1985-1999, suggesting increasingly unfavourable post-fire growing conditions, corresponding to significantly lower seedling densities and increased regeneration failure. Dry forests that already occur at the edge of their climatic tolerance are most prone to conversion to non-forests after wildfires. Major climate-induced reduction in forest density and extent has important consequences for a myriad of ecosystem services now and in the future.

Operative Time and Flap Failure in Unilateral and Bilateral Free Flap Breast Reconstruction.

BACKGROUND: There is an increasing trend toward bilateral breast reconstruction. Using the National Surgical Quality Improvement Program (NSQIP) database, we sought to understand the association between unilateral and bilateral free flap breast reconstruction and operative time and flap failure. METHODS: We selected a cohort of patients undergoing free flap breast reconstruction using the 2005 to 2010 NSQIP database. Cases were divided into unilateral and bilateral reconstruction. Subgroup analyses were performed dividing cases into delayed and immediate reconstruction. The effect of patient characteristics including age, body mass index (BMI), history of diabetes, and the American Society of Anesthesiologists' classification on operative time and flap failure was examined using univariable and multivariable regression models. Rates and odds ratios (OR) were reported using the multivariable gamma and logistic regression models, respectively. RESULTS: There were 691 free flap breast reconstructions performed in the cohort and 29.1% were bilateral cases. There was a 78-minute increase in the median operative time when comparing unilateral and bilateral reconstruction (p = 0.005). Patients undergoing bilateral reconstructions were generally younger and had fewer comorbidities compared with unilateral reconstructions. There was no significant association between bilateral reconstruction and flap failure. Immediate bilateral reconstructions had a significant increase in median operative time compared with immediate unilateral reconstructions (563 versus 480 minutes, p = 0.002) but no significant increase in operative time was noted when comparing delayed unilateral and delayed bilateral reconstructions. Prolonged operative time was associated with flap failure after adjusting for age and BMI (OR 1.17, p < 0.001). CONCLUSIONS: Bilateral free flap breast reconstruction can be performed safely despite an increase in operative time when compared with unilateral reconstruction.

Recent mountain pine beetle outbreaks, wildfire severity, and postfire tree regeneration in the US Northern Rockies.

Widespread tree mortality caused by outbreaks of native bark beetles (Circulionidae: Scolytinae) in recent decades has raised concern among scientists and forest managers about whether beetle outbreaks fuel more ecologically severe forest fires and impair postfire resilience. To investigate this question, we collected extensive field data following multiple fires that burned subalpine forests in 2011 throughout the Northern Rocky Mountains across a spectrum of prefire beetle outbreak severity, primarily from mountain pine beetle (Dendroctonus ponderosae). We found that recent (2001-2010) beetle outbreak severity was unrelated to most field measures of subsequent fire severity, which was instead driven primarily by extreme burning conditions (weather) and topography. In the red stage (0-2 y following beetle outbreak), fire severity was largely unaffected by prefire outbreak severity with few effects detected only under extreme burning conditions. In the gray stage (3-10 y following beetle outbreak), fire severity was largely unaffected by prefire outbreak severity under moderate conditions, but several measures related to surface fire severity increased with outbreak severity under extreme conditions. Initial postfire tree regeneration of the primary beetle host tree [lodgepole pine (Pinus contorta var. latifolia)] was not directly affected by prefire outbreak severity but was instead driven by the presence of a canopy seedbank and by fire severity. Recent beetle outbreaks in subalpine forests affected few measures of wildfire severity and did not hinder the ability of lodgepole pine forests to regenerate after fire, suggesting that resilience in subalpine forests is not necessarily impaired by recent mountain pine beetle outbreaks.

Female-to-Male Chest Reconstruction: A Review of Technique and Outcomes.

PURPOSE: Female-to-male transgender individuals frequently seek out chest wall masculinization as part of their gender transition and to aid with treating gender dysphoria. Critical evaluation of techniques, complications, and outcomes is important particularly as the surgery becomes more commonly performed. METHODS: A retrospective review was performed of all patients undergoing female-to-male chest wall reconstruction by the senior author from 2008 to 2015. Charts were reviewed to evaluate patient demographics, intraoperative details, and postoperative outcomes. Complications were stratified into major and minor complications based on the need to return to the operating room. Inframammary fold techniques and periareolar techniques cohorts were compared for major complications, minor complications, and need for revision surgeries. RESULTS: Over 8 years, 130 patients were identified. One hundred ten patients underwent inframammary fold techniques, and 20 patients underwent periareolar incisions. Early postoperative complications occurred in 25% of patients. Hematoma was the most common complications, occurring in 14% of patients. Major complications occurred in 8% of patients. Minor complications occurred in 16% of patients, with respiratory problems found to be a significant risk factor. On long-term follow up, 9% of patients had a revision procedure performed. Patients with prior breast surgery were more likely to require revisions (P = 0.009). Of patients requiring revision, 38% had a periareolar incision, compared with only 13% of patients who did not (P = 0.03). For unplanned revisions, there was no difference in periareolar and inframammary techniques. CONCLUSIONS: Our patient cohort demonstrates that female-to-male patients who undergo chest wall contouring through a transverse inframammary fold incision with either composite or standard free nipple grafting have decreased rates of revision surgery and trend toward having lower complication rates as compared with periareolar and limited scar techniques. To best manage expectations, patients undergoing a periareolar or other limited incision technique are counseled regarding an increased risk of hematoma and an increased likelihood of revisions.

Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction.

BACKGROUND: Female-to-male chest wall reconstruction is becoming more common, but while there is a growing body of the literature describing technique and algorithms, little detail is written on methods for creating a male appearing nipple areolar complex (NAC) from a female NAC utilizing free nipple graft techniques. Incorrect positioning of the NAC on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation. METHODS: With this paper, we present techniques for nipple grafting to achieve improved male appearing NACs, as well as a simple, reproducible method for appropriate placement of the NAC relative to the borders of the pectoralis muscle. To validate our technique, we performed photographic analysis of 64 NACs in 32 volunteers with BMI of 25 or less. RESULTS: The anatomic study determined the cis-male nipple to be positioned on average 2.5 cm medial to the lateral border of the pectoralis muscle and 2.4 cm above the inferior pectoralis insertion. This supports our surgical technique of positioning the NAC in relation to the pectoralis borders rather than previously advocated anatomic landmarks. We also present reliable techniques for creating a round or horizontally oval final NAC shape as well as a composite grafting technique for cases of large papillae. CONCLUSIONS: Our anatomic study supports placement of the male NAC relative to lateral and inferior borders of the pectoralis muscle. Nipple grafting techniques presented allow for a simple and reproducible method of creating an aesthetic male NAC shape in female-to-male transgender chest reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Burn me twice, shame on who? Interactions between successive forest fires across a temperate mountain region.

Increasing rates of natural disturbances under a warming climate raise important questions about how multiple disturbances interact. Escalating wildfire activity in recent decades has resulted in some forests re-burning in short succession, but how the severity of one wildfire affects that of a subsequent wildfire is not fully understood. We used a field-validated, satellite-derived, burn-severity atlas to assess interactions between successive wildfires across the US Northern Rocky Mountains a 300,000-km2 region dominated by fire-prone forests. In areas that experienced two wildfires between 1984 and 2010, we asked: (1) How do overall frequency distributions of burn-severity classes compare between first and second fires? (2) In a given location, how does burn severity of the second fire relate to that of the first? (3) Do interactions between successive fires vary by forest zone or the interval between fires? (4) What factors increase the probability of burning twice as stand-replacing fire? Within the study area, 138,061 ha burned twice between 1984 and 2010. Overall, frequency distributions of burn severity classes (low, moderate, high; quantified using relativized remote sensing indices) were similar between the first and second fires; however burn severity was 5-13% lower in second fires on average. Negative interactions between fires were most pronounced in lower-elevation forests and woodlands, when fire intervals were <10 yr, and when burn severity was low in the first fire. When the first fire burned as high severity and fire intervals exceeded 10-12 yr, burn-severity interactions switched from negative to positive, with high-severity fire begetting subsequent high-severity fire. Locations most likely to experience successive stand-replacing fires were high-elevation forests, which are adapted to high-severity fire, and areas conducive to abundant post-fire tree regeneration. Broadly similar severities among short-interval "re-burns" and other wildfires indicate that positive severity feedbacks, an oft-posited agent of ecosystem decline or state shift, are not an inevitable outcome of re-burning. Nonetheless, context-dependent shifts in both the magnitude and direction of wildfire interactions (associated with forest zone, initial burn-severity, and disturbance interval) illustrate complexities in disturbance interactions and can inform management and predictions of future system dynamics.

Spatial aspects of tree mortality strongly differ between young and old-growth forests.

Rates and spatial patterns of tree mortality are predicted to change during forest structural development. In young forests, mortality should be primarily density dependent due to competition for light, leading to an increasingly spatially uniform pattern of surviving trees. In contrast, mortality in old-growth forests should be primarily caused by contagious and spatially autocorrelated agents (e.g., insects, wind), causing spatial aggregation of surviving trees to increase through time. We tested these predictions by contrasting a three-decade record of tree mortality from replicated mapped permanent plots located in young (< 60-year-old) and old-growth (> 300-year-old) Abies amabilis forests. Trees in young forests died at a rate of 4.42% per year, whereas trees in old-growth forests died at 0.60% per year. Tree mortality in young forests was significantly aggregated, strongly density dependent, and caused live tree patterns to become more uniform through time. Mortality in old-growth forests was spatially aggregated, but was density independent and did not change the spatial pattern of surviving trees. These results extend current theory by demonstrating that density-dependent competitive mortality leading to increasingly uniform tree spacing in young forests ultimately transitions late in succession to a more diverse tree mortality regime that maintains spatial heterogeneity through time.

Spatially nonrandom tree mortality and ingrowth maintain equilibrium pattern in an old-growth Pseudotsuga-Tsuga forest.

Mortality processes in old-growth forests are generally assumed to be driven by gap-scale disturbance, with only a limited role ascribed to density-dependent mortality, but these assumptions are rarely tested with data sets incorporating repeated measurements. Using a 12-ha spatially explicit plot censused 13 years apart in an approximately 500-year-old Pseudotsuga-Tsuga forest, we demonstrate significant density-dependent mortality and spatially aggregated tree recruitment. However, the combined effect of these strongly nonrandom demographic processes was to maintain tree patterns in a state of dynamic equilibrium. Density-dependent mortality was most pronounced for the dominant late-successional species, Tsuga heterophylla. The long-lived, early-seral Pseudotsuga menziesii experienced an annual stem mortality rate of 0.84% and no new recruitment. Late-seral species Tsuga and Abies amabilis had nearly balanced demographic rates of ingrowth and mortality. The 2.34% mortality rate for Taxus brevifolia was higher than expected, notably less than ingrowth, and strongly affected by proximity to Tsuga. Large-diameter Tsuga structured both the regenerating conspecific and heterospecific cohorts with recruitment of Tsuga and Abies unlikely in neighborhoods crowded with large-diameter competitors (P < 0.001). Density-dependent competitive interactions strongly shape forest communities even five centuries after stand initiation, underscoring the dynamic nature of even equilibrial old-growth forests.

Fire severity and tree regeneration following bark beetle outbreaks: the role of outbreak stage and burning conditions.

The degree to which recent bark beetle (Dendroctonus ponderosae) outbreaks may influence fire severity and postfire tree regeneration is of heightened interest to resource managers throughout western North America, but empirical data on actual fire effects are lacking. Outcomes may depend on burning conditions (i.e., weather during fire), outbreak severity, or intervals between outbreaks and subsequent fire. We studied recent fires that burned through green-attack/red-stage (outbreaks <3 years before fire) and gray-stage (outbreaks 3­15 years before fire) subalpine forests dominated by lodgepole pine (Pinus contorta var. latifolia) in Greater Yellowstone, Wyoming, USA, to determine if fire severity was linked to prefire beetle outbreak severity and whether these two disturbances produced compound ecological effects on postfire tree regeneration. With field data from 143 postfire plots that burned under different conditions, we assessed canopy and surface fire severity, and postfire tree seedling density against prefire outbreak severity. In the green-attack/red stage, several canopy fire-severity measures increased with prefire outbreak severity under moderate burning conditions. Under extreme conditions, few fire-severity measures were related to prefire outbreak severity, and effect sizes were of marginal biological significance. The percentage of tree stems and basal area killed by fire increased with more green-attack vs. red-stage trees (i.e., the earliest stages of outbreak). In the gray stage, by contrast, most fire-severity measures declined with increasing outbreak severity under moderate conditions, and fire severity was unrelated to outbreak severity under extreme burning conditions. Postfire lodgepole pine seedling regeneration was unrelated to prefire outbreak severity in either post-outbreak stage, but increased with prefire serotiny. Results suggest bark beetle outbreaks can affect fire severity in subalpine forests under moderate burning conditions, but have little effect on fire severity under extreme burning conditions when most large wildfires occur in this system. Thus, beetle outbreak severity was moderately linked to fire severity, but the strength and direction of the linkage depended on both endogenous (outbreak stage) and exogenous (fire weather) factors. Closely timed beetle outbreak and fire did not impart compound effects on tree regeneration, suggesting the presence of a canopy seedbank may enhance resilience to their combined effects.

A rare case of venous sinus thrombosis and pulmonary embolisms secondary to myomatous erythrocytosis syndrome.

Myomatous erythrocytosis syndrome is a rare phenomenon of secondary polycythemia evolving from uterine leiomyoma. Although the underlying pathology is still unknown, patients have an increased risk of venous thrombosis. A 44-year-old GO (gravida zero) presented with an incidental finding of secondary polycythemia, and a diagnosis of myomatous erythrocytosis syndrome was made because of her large uterine fibroids. She was placed on therapeutic anticoagulation after developing pulmonary embolisms and a dural sinus venous thrombosis. Subsequently, she underwent uterine artery embolization, which resulted in a substantial decrease in her erythropoietin (8.1 mU/mL) along with hemoglobin (15.1 g/dL) and hematocrit (4 5g/dL). Myomatous erythrocytosis syndrome can cause venous thrombosis, leading to neurologic complications. In patients with increased risk for surgery, uterine artery embolization is an effective option for treatment.

Associations with Discharge to Post-Acute Care Facilities Among Patients Undergoing Open Reduction Internal Fixation of Distal Radius Fractures.

Introduction: Distal radius fractures are a common injury of the hand and wrist that often require intensive rehabilitation. We sought to identify risk factors associated with discharge to a post-acute care facility following distal radius fracture repair. Methods: The 2011 to 2016 National Surgical Quality Improvement Program® (NSQIP) database was queried for all Current Procedural Terminology (CPT) codes that corresponded with open distal radius fracture repair. Patients with concomitant traumatic injuries were excluded. Patient demographics, comorbidities, perioperative factors, laboratory data, and surgical details were collected. Our primary outcome was to determine postoperative discharge destination: home versus a post-acute care facility, and to identify factors that predict discharge to post-acute care facility. Secondary outcomes included unplanned readmission, reoperation, and complications. Results: Between 2011 and 2016, a total of 12,001 patients underwent open distal radius fracture repair and had complete information for their discharge. Of these analyzed patients, 3.24% (n = 389) were discharged to rehabilitation facilities. The following factors were identified on multivariate analysis to have an association with discharge to a post-acute care facility: 65 years or older, White race, underweight, using steroids preoperatively, American Society of Anesthesiologists (ASA) classification > 2, admitted from a nursing home or already hospitalized, anemic, undergoing bilateral surgery, wound classification other than clean, and complications prior to discharge. Conclusion: Factors identified by our study to have associations with discharge to post-acute care facilities following distal radius fracture repair can help in appropriate patient counseling and triage from the hospital to home versus a post-acute care facility.

Introduction: Les fractures du radius distal sont des blessures courantes de la main et du poignet qui exigent souvent une réadaptation intensive. Les chercheurs ont voulu déterminer les facteurs de risque associés au congé dans un établissement de soins post-aigus après la réparation d'une fracture du radius distal. Méthodologie: Les chercheurs ont fouillé la base de données 2011-2016 des NSQIP pour extraire tous les codes CPT (terminologie procédurale actuelle) qui correspondaient aux réparations des fractures ouvertes du radius distal. Les patients atteints d'autres blessures traumatiques ont été exclus. Les chercheurs ont colligé les caractéristiques démographiques des patients, leurs maladies sous-jacentes, les facteurs périopératoires, les données de laboratoire et l'information chirurgicale. Le résultat primaire consistait à déterminer la destination du congé postopératoire, soit le domicile ou l'établissement de soins postaigus, et à établir quels facteurs permettent de prédire un congé dans un établissement de soins postaigus. Les résultats secondaires incluaient des réadmissions non planifiées, la reprise de l'opération et les complications. Résultats: Entre 2011 et 2016, un total de 12 001 patients ont subi la réparation d'une fracture ouverte du radius distal et reçu de l'information complète lors de leur congé. De ce nombre, 3,24% (n = 389) ont obtenu leur congé dans des établissements de réadaptation. L'analyse multivariée a établi que les facteurs suivants étaient associés à un congé dans un établissement de soins postaigus : un âge de 65 ans ou plus, la race blanche, l'insuffisance pondérale, la prise de stéroïdes après l'opération, une classification d'ASA supérieure à 2, l'admission à partir d'un centre de soins de longue durée ou le fait d'être déjà hospitalisé, l'anémie, la chirurgie bilatérale, une classification des plaies autres que propre et des complications avant le congé. Conclusion: La présente étude a déterminé que certains facteurs associés au congé dans un établissement de soins postaigus après une réparation du radius distal peuvent contribuer à des conseils appropriés aux patients et à un triage de l'hôpital vers le domicile plutôt que vers un autre établissement.