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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.

This article uses evidence from the first Scottish Jesuits, sixteenth-century Scottish Catholic reformers, the use of the Quiñones breviary, a fireplace in Ballindalloch and the first Jesuit mission to Scotland in 1541–42 to argue that the early Jesuits had a greater influence on Scottish Catholic religion and spirituality in the mid-sixteenth century than has previously been noticed. It also suggests that the idea that the Scottish Protestant coup of 1559–60 was ‘the Scottish Reformation’ is profoundly confusing and that the presence of Jesuits, the use of the Spiritual Exercises of Ignatius Loyola and the implementation of the decrees of Trent in the Kingdom of Scotland before 1560 is not a ‘Counter-Reformation before the Reformation’ but just part of a series of movements of Catholic Reform that defined the Scottish Church in the century before the later missions of the Scottish Jesuits in 1578–1581.

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.

Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities.

We evaluated temporal trends in rural-urban disparities of the surgeon supply among surgeons commonly treating patients with cancer.We performed a retrospective observational study of county-level workforce changes from 2004 to 2017 using the Area Health Resource File. We calculated physician density (providers/100,000 population) for each specialty by rural and urban counties using the 2003 Rural-Urban Commuting Codes (RUCC), and evaluated percent changes in the rural-urban disparity in physician density. Secondary analyses evaluated these changes by Census region. Additionally, Gini indices were calculated by year and RUCC to evaluate the workforce inequality within rural areas.Total surgical specialist density declined in rural areas from 16 to 14 per 100,000 population, and declined slightly from 33 to 31 per 100,000 population in urban areas, for a rural-urban disparity increase of 8% (95% CI 5%,10%). Among specific specialties, the percentage increase in the rural-urban workforce supply disparity was largest for colorectal surgeons and general surgeons at 66% (95% CI 51%,80%) and 72% (95% CI 58%,86%), respectively, although absolute changes were small. Regional heterogeneity of the workforce was higher for rural areas than urban areas.Changes in the rural-urban physician workforce disparities over time are dependent upon specialty, region, and local community factors. This highlights how surgical workforce policy should be oriented to the local area circumstances.

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.

Purpose The purpose of this paper is to offer a viewpoint on the impact that the COVID-19 pandemic has had on people’s engagement with an online alcohol service in the UK. This paper examines whether self-reported mental health concerns increased during the pandemic compared to pre-pandemic times. Design/methodology/approach A comparison was made between service data captured in one contract area – West Sussex, England – pre-pandemic (April 2019 to March 2020) and during pandemic (April 2020 to March 2021). Findings Self-reported mental health treatment needs increased during the pandemic period (71.2% of presentations compared to 50% pre-pandemic) via the online coaching service. Male referrals increased by 74% during the pandemic period compared to the previous year. Female referrals decreased by 4% in the same time period. Feelings of shame and guilt as well as loss of a confidential space to engage in online interventions were common concerns reported by service users. Research limitations/implications Research limitations include the relatively small sample size, the sample comprised of self-referred treatment seeking clients, and there was no control group. All data collected is self-report therefore subjective and not necessarily meeting diagnostic criteria. Practical implications Of note was the impact of the pandemic on women and their reduced access to the online service during the pandemic. Commissioners and services must adapt their service design and delivery alongside the new “normal” way of living and working. Routine screening of mental health and alcohol use are recommended. Originality/value This paper offers insight from an established online/digital service and the impact of the pandemic on people’s engagement with the service.

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.

Radiation therapy often requires weeks of daily treatment making travel distance a known barrier to care. However, the full extent and variability of travel burden, defined by travel time, across the nation is poorly understood. Additionally, some states restrict radiation oncology (RO) services through Certificate of Need (CON) policies, but it is unknown how this affects travel times to care. Therefore, we aim to evaluate travel times to US RO facilities and assess the association with CON policies.RO facilities were identified from the 2018 National Plan and Provider Enumeration System (n = 2302). Travel times from populated US census tracts to nearest facility were calculated; differences by rurality, area deprivation, and region were computed. Multivariable linear regression was used to estimate adjusted differences in travel time by area characteristics. Logistic regression was used to assess the association of state CON laws with travel time1 hour.Among 72,471 census tracts, 92.4% were within 1 hour of the nearest radiation facility. Among the 12,453 rural tracts, 34.4% were1 hour. On adjusted analysis, the 3054 isolated rural tracts had an estimated 58-minute (95% confidence interval [CI] 57, 59; P.001) longer travel time than urban tracts. CON laws decreased rural travel time overall, but the association varied by region with decreased odds of prolonged travel in the South (P.001), increased odds in the Northeast and Midwest (P.001), and no association in the West (P = NS).Isolated rural US census tracts, accounting for 9.4 million Americans, have nearly 1-hour longer adjusted travel time to the nearest RO facility, compared with urban tracts. CON laws had region-dependent associations with prolonged travel.