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To determine whether rural Medicare FFS beneficiaries are more likely to be admitted to an urban hospital in 2018 than in 2010.We combined data from the 2010 to 2018 Hospital Service Area File (HSAF) and the 2010-2017 American Hospital Association (AHA) survey.We conducted a fixed-effects negative-binomial regression to determine whether urban hospital admissions from rural ZIP codes were increasing over time. We also conducted an exploratory geographically weighted regression.We transformed the HSAF data into a ZIP code-level file with all rural ZIP codes. We defined rural as having a Rural-Urban Commuting Area (RUCA) code ≥4. A hospital's system affiliation status was incorporated from the AHA survey.Controlling for distance to the nearest hospitals, an increase of 1 year was associated with a 2.0% increase (p 0.001) in the number of admissions to urban hospitals from each rural ZIP code. New system affiliation of the nearest rural hospital was associated with an increase of 1.7% (p 0.001).Even when controlling for distance to the nearest rural hospital (which reflects hospital closures), rural patients were increasingly likely to be admitted to an urban hospital.

To estimate the association of the Veterans Health Administration (VHA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) implemented in 2011 with caregiver health and health care use.VHA claims and electronic health records from May 2009 to May 2018.Using a retrospective, pre-post study design with inverse probability of treatment weights to address selection into treatment, we examine the association of PCAFC on caregivers who are veterans: (1) outpatient primary, specialty, and mental health care visits; (2) probability of uncontrolled hypertension and anxiety/depression; and (3) VHA health care costs. We compare outcomes for caregivers approved for PCAFC (treatment) to caregivers denied PCAFC (comparison).Not applicable.In the year pre-application, we observe similar probabilities of having any VHA primary care (~36%), VHA specialty care (~24%), and VHA or VHA-purchased mental health care (~22%) for treatment and comparison caregivers. In the year post-application, treated caregivers had a 5.89 percentage point larger probability of any outpatient VHA primary care (p = 0.002) and 4.34 percentage points larger probability of any outpatient mental health care use (p = 0.014). Post-application, probabilities of having uncontrolled hypertension or diagnosed anxiety/depression were higher for both treated and comparison groups. In the second year post-application, treated caregivers had a 1.88 percentage point larger probability of uncontrolled hypertension (p = 0.019) and 4.68 percentage points larger probability of diagnosed anxiety/depression (predicted probabilities: treated = 0.30; comparison = 0.25; p = 0.005). We find no evidence of differences in VHA total costs by PCAFC status.Our findings that PCAFC enrollment is associated with increased health care diagnosis and service use may reflect improved access for previously unmet needs in the population of veteran caregivers for veterans in PCAFC. The costs and value of these increases can be weighed against other effects of the program to inform national policies supporting caregivers.

We study a reinforcement process on graphs G of bounded degree. The model involves a parameter α > 0 governing the strength of reinforcement, and Poisson clock rates λ v at the vertices v of the graph. When the Poisson clock at a vertex v rings, one of the edges incident to it is reinforced, with edge e being chosen with probability proportional to its current count (counts start from 1) raised to the power α. The main problem in such models is to describe the (random) subgraph , consisting of edges that are reinforced infinitely often. In this paper, we focus on the finite connected components of in the strong reinforcement regime (α > 1) with clock rates that are uniformly bounded above. We show here that when α is sufficiently large, all connected components of are trees. When the firing rates λ v are constant, we show that all components are trees of diameter at most 3 when α is sufficiently large, and that there are infinitely many phase transitions as α ↓ 1 . For example, on the triangular lattice, increasingly large (odd) cycles appear as α ↓ 1 (while on the square lattice no finite component of contains a cycle for any α > 1). Increasingly long paths and other structures appear in both lattices when taking α ↓ 1 . In the special case where G = Z and α > 1, all connected components of are finite and we show that the possible cluster sizes are non-monotone in α. We also present several open problems.

Aggregation of children in schools has been established to be a key driver of transmission of infectious diseases. Mathematical models of transmission used to predict the impact of control measures, such as vaccination and testing, commonly depend on self-reported contact data. However, the link between self-reported social contacts and pathogen transmission has not been well described. To address this, we used Staphylococcus aureus as a model organism to track transmission within two secondary schools in England and test for associations between self-reported social contacts, test positivity and the bacterial strain collected from the same students. Students filled out a social contact survey and their S. aureus colonization status was ascertained through self-administered swabs from which isolates were sequenced. Isolates from the local community were also sequenced to assess the representativeness of school isolates. A low frequency of genome-linked transmission precluded a formal analysis of links between genomic and social networks, suggesting that S. aureus transmission within schools is too rare to make it a viable tool for this purpose. Whilst we found no evidence that schools are an important route of transmission, increased colonization rates found within schools imply that school-age children may be an important source of community transmission.

We study the so-called frog model on ${\mathbb{Z}}$ with two types of lazy frogs, with parameters $p_1,p_2\in (0,1]$ respectively, and a finite expected number of dormant frogs per site. We show that for any such $p_1$ and $p_2$ there is positive probability that the two types coexist (i.e. that both types activate infinitely many frogs). This answers a question of Deijfen, Hirscher, and Lopes in dimension one.

We previously showed increased steroid-resistant CD28null CD8+ senescent lymphocyte subsets in the peripheral blood from patients with chronic obstructive pulmonary disease (COPD). These cells expressed decreased levels of the glucocorticoid receptor (GCR), suggesting their contribution to the steroid-resistant property of these cells. COPD is a disease of the small airways (SA). We, therefore, hypothesized that there would be a further increase in these steroid-resistant lymphocytes in the lung, particularly in the SA. We further hypothesized that the pro-inflammatory/cytotoxic potential of these cells could be negated using prednisolone with low-dose cyclosporin A. Blood, bronchoalveolar lavage, large proximal, and small distal airway brushings were collected from 11 patients with COPD and 10 healthy aged-matched controls. The cytotoxic mediator granzyme b, pro-inflammatory cytokines IFNγ/TNFα, and GCR were determined in lymphocytes subsets before and after their exposure to 1µM prednisolone and/or 2.5 ng/mL cyclosporin A. Particularly in the SA, COPD subjects showed an increased percentage of CD28null CD8 T-cells and NKT-like cells, with increased expression of granzyme b, IFNγ and TNFα and a loss of GCR, compared with controls. Significant negative correlations between SA GCR expression and IFNγ/TNFα production by T and NKT-like cells (eg, T-cell IFNγ R = −0.834, P = 0.031) and with FEV1 (R = −0.890) were shown. Cyclosporine A and prednisolone synergistically increased GCR expression and inhibited pro-inflammatory cytokine production by CD28null CD8− T and NKT-like cells. COPD is associated with increased pro-inflammatory CD28null CD8+ T and NKT-like cells in the SA. Treatments that increase GCR in these lymphocyte subsets may improve the efficacy of clinical treatment.

Global change encompasses many co-occurring anthropogenic drivers, which can act synergistically or antagonistically on ecological systems. Predicting how different global change drivers simultaneously contribute to observed biodiversity change is a key challenge for ecology and conservation. However, we lack the mechanistic understanding of how multiple global change drivers influence the vital rates of multiple interacting species. We propose that reaction norms, the relationships between a driver and vital rates like growth, mortality, and consumption, provide insights to the underlying mechanisms of community responses to multiple drivers. Understanding how multiple drivers interact to affect demographic rates using a reaction-norm perspective can improve our ability to make predictions of interactions at higher levels of organization-that is, community and food web. Building on the framework of consumer-resource interactions and widely studied thermal performance curves, we illustrate how joint driver impacts can be scaled up from the population to the community level. A simple proof-of-concept model demonstrates how reaction norms of vital rates predict the prevalence of driver interactions at the community level. A literature search suggests that our proposed approach is not yet used in multiple driver research. We outline how realistic response surfaces (i.e., multidimensional reaction norms) can be inferred by parametric and nonparametric approaches. Response surfaces have the potential to strengthen our understanding of how multiple drivers affect communities as well as improve our ability to predict when interactive effects emerge, two of the major challenges of ecology today.

We prove that the rescaled historical processes associated to critical spread-out lattice trees in dimensions$$d>8$$d>8converge to historical Brownian motion. This is a functional limit theorem for measure-valued processes that encodes the genealogical structure of the underlying random trees. Our results are applied elsewhere to prove that random walks on lattice trees, appropriately rescaled, converge to Brownian motion on super-Brownian motion.

OBJECTIVE: Between January 2005 and July 2020, 171 rural hospitals closed across the United States. Little is known about the extent that other providers step in to fill the potential reduction in access from a rural hospital closure. The objective of this analysis is to evaluate the trends of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in rural areas prior to and following hospital closure. DATA SOURCES/STUDY SETTING: We used publicly available data from Centers for Medicare and Medicaid Provider of Services files, Cecil G. Sheps Center rural hospital closures list, and Small Area Income and Poverty Estimates. STUDY DESIGN: We described the trends over time in the number of hospitals, hospital closures, FQHC sites, and RHCs in rural and urban ZIP codes, 2006–2018. We used two‐way fixed effects and pooled generalized linear models with a logit link to estimate the probabilities of having any RHC and any FQHC within 10 straight‐line miles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Compared to hospitals that never closed, the predicted probability of having any FQHC within 10 miles increased post closure by 5.95 and 11.57 percentage points at 1 year and 5 years, respectively (p

Human milk oligosaccharides (HMOs) are complex glycans associated with positive infant health outcomes. The concentrations of HMOs in the milk of lactating women are associated with substantial intra- and inter-individual differences and may be influenced by maternal physiological and/or nutrition-related factors. The primary aim of this study was to explore potential influences of short-term maternal diet and current body composition on HMO profiles in mature human milk. Milk samples were collected at 3–4 months postpartum from 101 healthy Australian women using standardised procedures, and analysed for macronutrients (lactose, fat, and protein). In addition, HMO concentrations were analysed using liquid-chromatography mass-spectrometry (LC-MS). Maternal dietary data were collected using three validated 24-h dietary recalls, and the body composition of a subgroup of mothers was assessed by DEXA scans (n = 30). Most (79%) of the women were secretor-positive. Individual nutrients were not significantly correlated with HMO concentrations after correction for multiple comparisons (p > 0.05), except for dietary folate intake. DEXA scans revealed no associations between HMO profiles and maternal body composition during established lactation. The study findings suggest a lack of clear and consistent associations between maternal nutrition and HMO concentrations in mature human milk from healthy lactating women with adequate dietary intake. The prevailing influence of genetic variation in lactating mothers may overshadow any impact of maternal nutritional and/or physiological status on HMO composition in mature human milk.

Alongside the many mainstream plastics technologies on show at the triennial K 2019 show gathering in Düsseldorf, Germany, a number of new composite manufacturing processes and materials were presented. Reinforced Plastics highlights some examples.

Objectives. To quantify the number of people in the US who delay medical care annually because of lack of available transportation and to examine the differential prevalence of this barrier for adults across sociodemographic characteristics and patient populations. Methods. We used data from the National Health Interview Survey (1997–2017) to examine this barrier over time and across groups. We used joinpoint regression analysis to identify significant changes in trends and multivariate analysis to examine correlates of this barrier for the year 2017. Results. In 2017, 5.8 million persons in the United States (1.8%) delayed medical care because they did not have transportation. The proportion reporting transportation barriers increased between 2003 and 2009 with no significant trends before or after this window within our study period. We found that Hispanic people, those living below the poverty threshold, Medicaid recipients, and people with a functional limitation had greater odds of reporting a transportation barrier after we controlled for other sociodemographic and health characteristics. Conclusions. Transportation barriers to health care have a disproportionate impact on individuals who are poor and who have chronic conditions. Our study documents a significant problem in access to health care during a time of rapidly changing transportation technology.

Injection molding machine manufacturers are looking to bring their expertise of large quantity part production to the composite industry.

We study the behaviour of a sequence of biased random walks X(i), i>=0 on a sequence of random graphs, where the initial graph is Zd and otherwise the graph for the i-th walk is the trace of the (i - 1)-st walk. The sequence of bias vectors is chosen so that each walk is transient. We prove the aforementioned transience and a law of large numbers, and provide criteria for ballisticity and sub-ballisticity. We give examples of sequences of biases for which each X(i), i>=1 is (transient but) not ballistic, and the limiting graph is an infinite simple (self-avoiding) path. We also give examples for which each X(i), i>=1 is ballistic, but the limiting graph is not a simple path., 36 pages

Assisted living memory care (ALMC) residents present with specific needs and challenges. Knowledge regarding their nutritional intake and the relationship to cognitive ability, demographics, and dining behaviors is limited. This quality improvement project was conducted to determine the dietary intake of ALMC residents and identify factors related to the adequacy of their dietary intake to inform the development of strategies to enhance their dietary intake. Ingested food and fluids and ingestion behaviors were recorded over a 12-hour (7 AM -7 PM) observation. Related factors examined were obtained from chart review. Food Processor Nutritional Analysis Software was used to determine nutrient intake with the calculation of percent of recommended amounts based on BMI, age, and activity level. Thirty-two residents (75% females; mean age 86.5 years, SD=7.84) of four ALMC units (eight per unit) were subjects of this study. Their Global Deterioration Scores ranged from 3 to 7, with 60% at 5 or greater. Average BMI was 25.47 kg/m2 (range 14.1-40.4 kg/m2). Major dietary components (protein, calories, carbohydrates) were consumed in adequate amounts based on the percent of recommended. The percent of recommended fiber intake was low (mean 61.57%) with saturated fat intake extremely high (mean 243.80%). Micronutrients were below recommended levels except for cholesterol, vitamin C, sodium, and iron. Four subject groups, relative to level (inadequate, moderately inadequate, adequate, exceeds recommended) of nutritional intake, were identified based on hierarchical clustering with all nutrient data. Using protein intake as a representative nutrient variable, regression analysis indicated that 44.1% of the variance was explained by cognitive ability and setting after adjusting for their interaction. A balance of adequate intake while allowing ALMC residents’ choice in food selection is essential. Further research is needed to address dining standards specific to the ALMC population that recognizes cognitive ability, food offerings, and dining behaviors.

Introduction Influenza is a common cause of acute respiratory infection, and is a major cause of morbidity and mortality. Coronavirus disease 2019 (COVID-19) is an acute respiratory infection that emerged as a pandemic worldwide before the start of the 2020 Australian influenza season. This report summarises the epidemiology of hospitalisations with laboratory-confirmed influenza and COVID-19 during the 2020 influenza season in a sentinel surveillance system. Methods The Influenza Complications Alert Network (FluCAN) is a sentinel hospital-based surveillance program that operates at sites in all jurisdictions in Australia. Influenza and COVID-19 cases were defined as patients hospitalised at sentinel hospitals and confirmed by nucleic acid detection. Results There were 448 patients with COVID-19 admitted between 16 March and 31 December 2020, and only 20 patients with influenza admitted between 1 April and 30 November 2020, to one of 22 FluCAN hospitals. Of the COVID-19 cases, 173 (39%) were > 65 years of age, 36 (8%) were children (< 16 years), 6 (1%) were Aboriginal and Torres Strait Islander peoples, 4 (1%) were pregnant and 289 (65%) had chronic comorbidities. COVID-19 hospital admissions peaked between weeks 13 and 15 (first wave) nationally, and again between weeks 31 and 35 (Victoria), with most admissions represented by those above 40 years of age. Discussion There was an unusually low number of hospital admissions with laboratory-confirmed influenza in this season, compared to recent seasons. This is likely to be due to effective public health interventions and international border closures as a result of a rise in COVID-19 respiratory infections and associated hospitalisations.

Flow cytometry is often employed in ecology to measure traits and population size of bacteria and phytoplankton. This technique allows measuring millions of particles in a relatively small amount of time. However, distinguishing between different populations is not a straightforward task. Gating is a process in the identification of particles measured in flow cytometry. Gates can either be created manually using known characteristics of these particles, or by using automated clustering techniques. Available automated techniques implemented in statistical packages for flow cytometry are primarily developed for medicinal applications, while only two exist for phytoplankton. cyanoFilter is an R package built to identify phytoplankton populations from flow cytometry data. The package also integrates gating functions from two other automated algorithms. It also provides a gating accuracy test function that can be used to determine the accuracy of a desired gating function if monoculture flowcytometry data is available. The central algorithm in the package exploits observed pigmentation and granularity of phytoplankton cells. We demonstrate how its performance depends on strain similarity, using a model system of six cyanobacteria strains. Using the same system, we compare the performance of the central gating function in the package to similar functions in other packages.

Advances in machine technology and improvements in materials are progressing the use of additive manufacturing in the composites market – from prototypes to customized products. Reinforced Plastics reviews some recent developments.

Lack of high throughput phenotyping systems for determining moisture content during the maize nixtamalization cooking process has led to difficulty in breeding for this trait. This study provides a high throughput, quantitative measure of kernel moisture content during nixtamalization based on NIR scanning of uncooked maize kernels. Machine learning was utilized to develop models based on the combination of NIR spectra and moisture content determined from a scaled-down benchtop cook method. A linear support vector machine (SVM) model with a Spearman’s rank correlation coefficient of 0.852 between wet lab and predicted values was developed from 100 diverse temperate genotypes grown in replicate across two environments. This model was applied to NIR data from 501 diverse temperate genotypes grown in replicate in five environments. Analysis of variance revealed environment explained the highest percent of the variation (51.5%), followed by genotype (15.6%) and genotype-by-environment interaction (11.2%). A genome-wide association study identified 26 significant loci across five environments that explained between 5.04% and 16.01% (average = 10.41%). However, genome-wide markers explained 10.54% to 45.99% (average = 31.68%) of the variation, indicating the genetic architecture of this trait is likely complex and controlled by many loci of small effect. This study provides a high-throughput method to evaluate moisture content during nixtamalization that is feasible at the scale of a breeding program and provides important information about the factors contributing to variation of this trait for breeders and food companies to make future strategies to improve this important processing trait.Key MessageMoisture content during nixtamalization can be accurately predicted from NIR spectroscopy when coupled with a support vector machine (SVM) model, is strongly modulated by the environment, and has a complex genetic architecture.

We study a particular model of a random medium, called the orthant model, in general dimensions $d\ge 2$. Each site $x\in \Z^d$ independently has arrows pointing to its positive neighbours $x+e_i$, $i=1,\dots, d$ with probability $p$ and otherwise to its negative neighbours $x-e_i$, $i=1,\dots, d$ (with probability $1-p$). We prove a shape theorem for the set of sites reachable by following arrows, starting from the origin, when $p$ is large. The argument uses subadditivity, as would be expected from the shape theorems arising in the study of first passage percolation. The main difficulty to overcome is that the primary objects of study are not stationary, which is a key requirement of the subadditive ergodic theorem.

Reliable intelligence lies at the heart of learning societies. Robust, accessible evidence of current and future skills needs informs policy and planning, helps target investment, improves the quality of education and training, and encourages dialogue and action among stakeholders. Change is continuous and inevitable, but systematic and comprehensive approaches to gathering and using intelligence are essential tools if sectors, communities, and economies are to learn, adapt, and thrive. This chapter discusses how an innovative skills intelligence model designed by the National Academy for Rail in the United Kingdom has been applied to develop a workforce planning strategy for the rail sector. This has enabled the sector to build a continuous learning and training approach that underpins its safe operation, contributes to improved productivity and profitability, and helps to anticipate the impact of potential disruption, including from new technology, demographic trends, and global pandemics.

The aim of online monitoring is to issue an alarm as soon as there is significant evidence in the collected observations to suggest that the underlying data generating mechanism has changed. This work is concerned with open-end, nonparametric procedures that can be interpreted as statistical tests. The proposed monitoring schemes consist of computing the so-called retrospective CUSUM statistic (or minor variations thereof) after the arrival of each new observation. After proposing suitable threshold functions for the chosen detectors, the asymptotic validity of the procedures is investigated in the special case of monitoring for changes in the mean, both under the null hypothesis of stationarity and relevant alternatives. To carry out the sequential tests in practice, an approach based on an asymptotic regression model is used to estimate high quantiles of relevant limiting distributions. Monte Carlo experiments demonstrate the good finite-sample behavior of the proposed monitoring schemes and suggest that they are superior to existing competitors as long as changes do not occur at the very beginning of the monitoring. Extensions to statistics exhibiting an asymptotic mean-like behavior are briefly discussed. Finally, the application of the derived sequential change-point detection tests is succinctly illustrated on temperature anomaly data., 41 pages, 7 figures, 3 tables, some typos fixed

We study a class of reinforcement models involving a Poisson process on the vertices of certain infinite graphs G. When a vertex fires, one of the edges incident to that vertex is selected. The edge selection is biased towards edges that have been selected many times previously, and a parameter α governs the strength of this bias. We show that for various graphs (including all graphs of bounded degree), if α 1 (the very strong reinforcement regime) then the random subgraph consisting of edges that are ever selected by this process does not percolate (all connected components are finite). Combined with results appearing in a companion paper, this proves that on these graphs, with α sufficiently large, all connected components are in fact trees. If the Poisson firing rates are constant over the vertices, then these trees are of diameter at most 3. The proof of nonpercolation relies on coupling with a percolation-type model that may be of interest in its own right.

The assessment of body composition during lactation is an important indicator of maternal nutritional status, which is central to the overall health of the mother and child. The lactating woman’s nutritional status potentially impacts on breastmilk composition and the process of lactation itself. The purpose of this scoping review was to synthesize comparative studies that sought to validate various body composition assessment techniques for use in lactating women in the postpartum period. Using the PRISMA-ScR guidelines, a comprehensive, systematic literature search was conducted using Scopus, Web of Science, and PubMed. Eight comparative studies were included in the review, with data from 320 postpartum women. The design methodologies varied substantially across studies, and included a range of simple techniques to advanced multi-compartment models for assessing body composition. The validity and reliability of measurement tools must be considered alongside issues of safety, practicality, and appropriateness to guide the research design when applied to lactating women.

BackgroundBK virus-associated nephropathy (BKVAN) is a relatively common cause of renal dysfunction in the first six months after renal transplantation. It arises from reactivation of the latent and usually harmless BK virus (BK virus) due to immunosuppression and other factors including some that are unique to renal transplantation such as allograft injury. BKVAN is much rarer in non-renal solid organ transplantation, where data regarding diagnosis and management are extremely limited.Case presentationWe report a case of a 58-year-old man found to have worsening renal dysfunction nine months after bilateral sequential lung transplantation for chronic obstructive pulmonary disease (COPD). He had required methylprednisolone for acute allograft rejection but achieved good graft function. Urine microscopy and culture and renal ultrasound were normal. BK virus PCR was positive at high levels in urine and blood. Renal biopsy subsequently confirmed BKVAN. The patient progressed to end-stage renal failure requiring haemodialysis despite reduction in immunosuppression, including switching mycophenolate for everolimus, and the administration of intravenous immunoglobulin (IVIG).ConclusionsThis very rare case highlights the challenges presented by BK virus in the non-renal solid organ transplant population. Diagnosis can be difficult, especially given the heterogeneity with which BKV disease has been reported to present in such patients, and the optimal approach to management is unknown. Balancing reduction in immunosuppression against prevention of allograft rejection is delicate. Improved therapeutic options are clearly required.

Purpose During the COVID‐19 epidemic, it is critical to understand how the need for hospital care in rural areas aligns with the capacity across states. Methods We analyzed data from the 2018 Behavioral Risk Factor Surveillance System to estimate the number of adults who have an elevated risk of serious illness if they are infected with coronavirus in metropolitan, micropolitan, and rural areas for each state. Study data included 430,949 survey responses representing over 255.2 million noninstitutionalized US adults. For data on hospital beds, aggregate survey data were linked to data from the 2017 Area Health Resource Files by state and metropolitan status. Findings About 50% of rural residents are at high risk for hospitalization and serious illness if they are infected with COVID‐19, compared to 46.9% and 40.0% in micropolitan and metropolitan areas, respectively. In 19 states, more than 50% of rural populations are at high risk for serious illness if infected. Rural residents will generate an estimated 10% more hospitalizations for COVID‐19 per capita than urban residents given equal infection rates. Conclusion More than half of rural residents are at increased risk of hospitalization and death if infected with COVID‐19. Experts expect COVID‐19 burden to outpace hospital capacity across the country, and rural areas are no exception. Policy makers need to consider supply chain modifications, regulatory changes, and financial assistance policies to assist rural communities in caring for people affected by COVID‐19.

Wider use of carbon fiber in the composites industry is now a possibility through the introduction of recycled materials. Reinforced Plastics reports on the development of recycled carbon fibers by ELG Carbon Fibre and how some key industrial partners are using them.

Context The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year. Objective The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases. Methods We analyzed monthly hospice outcomes using 2012–2013 Medicare claims. Results Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges. Conclusion Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care.

Summary Immunosuppressive therapy fails to suppress the production of proinflammatory cytokines, particularly by CD8+ T cells, in stable lung transplant recipients and those undergoing chronic rejection, suggesting that some patients may become relatively resistant to immunosuppressants such as glucocorticoids (GC). We have shown loss of GC receptor (GCR) from the CD8+ cells, and we hypothesized that the drug membrane efflux pump, p-glycoprotein-1 (Pgp), may also be involved in lymphocyte steroid resistance following lung transplant. Pgp/GCR expression and interferon (IFN)-γ/tumour necrosis factor (TNF)-α proinflammatory cytokine production was measured in blood lymphocytes from 15 stable lung transplant patients, 10 patients with bronchiolitis obliterans syndrome (BOS) and 10 healthy aged-matched controls (± prednisolone ± Pgp inhibitor, cyclosporin A ± GCR activator, Compound A) using flow cytometry. Both Pgp+ and Pgp– lymphocyte subsets from all subjects produced IFN-γ/TNF-α proinflammatory cytokines. Pgp expression was increased in CD8+Pgp+ T cells and correlated with IFN-γ/TNF-α expression and BOS grade. Reduced GCR was observed in CD8+Pgp– T, natural killer (NK) T-like and NK cells from stable patients compared with controls, and reduced further in CD8+Pgp– T cells in BOS. The addition of 2·5 ng/ml cyclosporin A and 1 µM prednisolone inhibit IFN-γ/TNF-α production significantly by CD8+Pgp+ T cells from BOS patients. The addition of 10 µM Compound A and 1 µM prednisolone inhibit IFN-γ/TNF-α production significantly by CD8+Pgp– T cells from BOS patients. BOS is associated with increased Pgp expression and loss of GCR from steroid-resistant proinflammatory CD8+ T cells. Treatments that inhibit Pgp and up-regulate GCR in CD8+ T cells may improve graft survival.