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Background: Significant primary care provider (PCP) shortage exists in the United States. Expanding the scope of practice for nurse practitioners (NPs) and physician assistants (PAs) can help alleviate this shortage. The Department of Veterans' Affairs (VA) has been a pioneer in expanding the role of NPs and PAs in primary caregiving. Purpose: This study evaluated the health care costs associated with VA patients cared for by NPs and PAs versus primary care physicians (physicians). Methods: A retrospective data analysis using two separate cohorts of VA patients, one with diabetes and the other with cardiovascular disease (CVD), was performed. The associations between PCP type and health care costs were analyzed using ordinary least square regressions with logarithmically transformed costs. Results: The analyses estimated 12% to 13% (US dollars [USD] 2,626) and 4% to 5% (USD 924) higher costs for patients assigned to physicians as compared with those assigned to NPs and PAs, after adjusting for baseline patient sociodemographics and disease burden, in the diabetes and CVD cohort, respectively. Given the average patient population size of a VA medical center, these cost differences amount to a total difference of USD 14 million/year per center and USD 5 million/year per center for diabetic and CVD patients, respectively. Implications for practice: This study highlights the potential cost savings associated with primary caregiving by NPs and PAs. In light of the PCP shortage, the study supports increased involvement of NPs and PAs in primary caregiving. Future studies examining the reasons for these cost differences by provider type are required to provide more scientific evidence for regulatory decision making in this area. [ABSTRACT FROM AUTHOR]

Presents the text of the dissertation given by David Ramsey, a statesman and medical practitioner in South California, which is focused on pediatric care.

Background: Medical comorbidities and functional status limitations are determinants of mortality in many chronic diseases. The extent to which survival in the rapidly aging cohort of patients with HCV is affected by these competing causes of mortality remains unclear.Aim: We sought to determine the effect of medical/functional comorbidities on survival after adjusting for liver disease severity in a cohort of patients with HCV infection.Methods: We prospectively recruited consecutive patients from an HCV clinic 2009-2014. We calculated an index of survival (Schonberg Index, SI) based on age, gender, medical comorbidities, and functional status variables. We defined cirrhosis with the FibroSure test (F3/4-F4). We used multivariable Cox modeling to assess association between functional/survival measure and survival after adjustment for severity of liver disease.Results: The cohort consisted of 1052 HCV patients. The average age was 56.8 years; 36 % had cirrhosis. The mean SI was 8.2 (SD = 2.7). During a mean follow-up of 5610 person-years, 102 (9.7 %) patients died. In unadjusted analysis, higher baseline SI predicted mortality (HR 1.17; 95 % CI 1.09-1.25). SI similarly predicted mortality in cirrhotic patients (HR 1.23, 95 % CI 1.13-1.34) and non-cirrhotic patients (HR 1.21, 95 % CI 1.08-1.36). This did not change after adjusting for age, drug use, or coronary artery disease.Discussion: Comorbidities and functional limitations predict higher mortality in patients with HCV; this relationship is independent of cirrhosis. Use of general prognostic indices may help identify HCV patients at high risk for mortality, which could further guide clinical care in a manner not achievable with assessment of liver disease alone. [ABSTRACT FROM AUTHOR]

The article discusses several medical-related topics. These include the rising healthcare disparities in the U.S. despite the enactment of the Patient Protection and Affordable Care Act in 2010, the outcomes of the 2006 implementation of the routine rotavirus vaccination for children and the potential negative effects of a last-minute amendment to the Newborn Screening Saves Lives Reauthorization Act, such as reduction in newborn screening participation.

Discusses how the staff of the Iowa Methodist Medical Center in Des Moines delivered quality patient care during the flood crisis in July 1993. Description of the impact of the floods on the hospital facilities; Coping with contaminated drinking water; Preparations for the floods; Emergency management actions; Lessons in communication; Roles of employees.

The authors describe the framework their department has adopted to incorporate the attainment of Hansen's (1986) proficiencies into the curriculum. Major changes include the identification of tools students should be able to use to complete specific activities, significant changes in prerequisites for upper- division courses, and the development of a capstone experience designed to bring together the various tools the student has been introduced to as he or she proceeds through the major. They believe that the design characteristics of their capstone experience promote the achievement of Hansen's proficiencies, and the framework described here could be easily adopted by other departments. [ABSTRACT FROM AUTHOR]

Awareness of negative health impacts associated with food insecurity among US veterans is growing. Yet, little research has examined characteristics associated with persistent vs transient food insecurity. Our aim was to investigate characteristics associated with persistent vs transient food insecurity among US veterans. The study used a retrospective, observational design to examine data from Veterans Health Administration electronic medical records. The sample consisted of veterans (n = 64,789) who screened positive for food insecurity in Veterans Health Administration primary care during fiscal years 2018-2020 and were rescreened within 3 to 5 months. Food insecurity was operationalized using the Veterans Health Administration food insecurity screening question. Transient food insecurity was a positive screen followed by a consecutive negative screen within 3 to 15 months. Persistent food insecurity was a positive screen followed by a consecutive positive screen within 3 to 15 months. A multivariable logistic regression model was used to assess characteristics (eg, demographic characteristics, disability rating, homelessness, and physical and mental health conditions) associated with persistent vs transient food insecurity. Veterans with increased odds of persistent vs transient food insecurity included men (adjusted odds ratio [AOR] 1.08; 95% CI 1.01 to 1.15) and those from Hispanic (AOR 1.27; 95% CI 1.18 to 1.37) or Native American (AOR 1.30; 95% CI 1.11 to 1.53) racial and ethnic groups. Psychosis (AOR 1.16; 95% CI 1.06 to 1.26); substance use disorder, excluding tobacco and alcohol (AOR 1.11; 95% CI 1.03 to 1.20); and homelessness (AOR 1.32; 95% CI 1.26 to 1.39) were associated with increased odds of persistent vs transient food insecurity. Veterans who were married (AOR 0.87; 95% CI 0.83 to 0.92) or had a service-connected disability rating of 70% to 99% (AOR 0.85; 95% CI 0.79 to 0.90) or 100% (AOR 0.77; 95% CI 0.71 to 0.83) had lower odds of persistent vs transient food insecurity. Veterans at risk for persistent vs transient food insecurity may struggle with underlying issues like psychosis, substance use, and homelessness in addition to racial and ethnic inequities and gender differences. More research is needed to understand the characteristics and mechanisms that increase risk for persistent vs transient food insecurity among veterans. [ABSTRACT FROM AUTHOR]

Organellar genomes are considered to be strictly uniparentally-inherited. Uniparental inheritance allows for cytonuclear coevolution and the development of highly coordinated cytonuclear interactions. Yet, instances of biparental inheritance have been documented across eukaryotes. Biparental inheritance in otherwise uniparentally-inherited organelles is termed leakage (maternal or paternal) and allows for the presence of multiple variants of the same organellar genome within an individual, called heteroplasmy. It is unclear what, if any, evolutionary consequences are placed on nuclear and/or organellar genomes due to heteroplasmy. One way of accessing cytonuclear interactions and potential coevolution is through calculating cytonuclear linkage disequilibrium (cnLD), or the non-random association of alleles between nuclear and organellar genomes. Patterns of cnLD can indicate positive or negative cytonuclear selection, coevolution between the nuclear and organellar genomes, non-traditional organellar inheritance, or instances of ancestral heteroplasmy. In plants, cytonuclear interactions have been shown to play a role in cytoplasmic male sterility which occurs in gynodioecious species and is associated with leakage. We used the gynodioecious species, Daucus carota L. spp. carota , or wild carrot, to investigate cnLD. We genotyped a total of 265 individuals from two regions of the USA at 15 nuclear microsatellites, the mitochondrial genes cox1 and atp9 , and an intergenic region between trnS and trnG (StoG) in the plastid genome to calculate nuclear–nuclear LD (nucLD), cnLD, and organellar LD (i.e. within the mtDNA and between mtDNA and ptDNA) within the two regions. We were further able to identify cox1 and StoG heteroplasmy and calculate some of the same LD measures within heteroplasmic and homoplasmic (non-heteroplasmic) datasets. We used a Z-transformation test to demonstrate that heteroplasmic individuals display significantly higher levels of cnLD within both regions. In spite of this, within and between organellar LD is low to moderate. Given these patterns of LD in two regions of the USA in which gene flow has been shown to occur between crop and wild carrot, we suggest that heteroplasmy is an evolutionary mechanism which permits the maintenance of cnLD while also acting to disrupt organellar LD. [ABSTRACT FROM AUTHOR]

Historians have argued that disestablishment liberated American religion and allowed for the proliferation of religious practice and religious freedom, especially individualistic Evangelicalism in the South. This proposition reduced nearly all of southern Protestantism to Revivalist Evangelicalism, and failed to account for the powerful presence of coercive Protestant religiosity in older southern states such as South Carolina. While they shared certain Evangelical particulars with frontier populations, Protestants in South Carolina, especially Presbyterians, rejected individualized religion in favor of religiosity that favored and nurtured activist state protection of both antidemocratic political norms and chattel slavery. This essay argues that ostensibly disestablished Presbyterianism in South Carolina helped intellectually erect and socially perpetuate coercive religious and state power. [ABSTRACT FROM AUTHOR]

Implementation of the insurance-exchange and Medicaid-expansion provisions of the Affordable Care Act offers an opportunity to analyze the sources and extent of state and federal government leverage in bargaining over the rollout of a major federal program. What stands out from this study is state officials’ ability to leverage their administrative capacity and policy expertise as well as their power to decline participation in federal programs in order to influence implementation of a federal initiative. State officials’ influence is heightened when the program depends on state participation to achieve key federal objectives, when state threats to decline participation are meaningful, and when state nonparticipation threatens the success of a signature item on a president’s policy agenda. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to investigate the differential classroom structure and efficacy reported by general and special educators at the elementary and secondary level. General and special educators (n = 774, return rate of 37%) from a large school district in the southeast US participated in the study. The participants completed a modified version of the Bender Classroom Structure Questionnaire in order to determine their use of cognitive strategies, management strategies, and individualized instructional strategies. In addition, the teachers completed a modified version of the Teacher Efficacy Scale to probe their efficacy in serving students with disabilities. A Multivariate Analysis of Variance (MANOVA) was conducted to determine level of variance within and between participants. Findings indicate differences in classroom structure between elementary and secondary settings and that special and general educators differed in their instructional practices. [ABSTRACT FROM AUTHOR]

This paper examines the role of Cold War military systems science in the emergence of a nonlinear view of war within the US military. It argues that US military ambivalence towards systems science and seeds of a nonlinear worldview within the systems sciences help to explain the enlistment of nonlinear sciences like chaos and complexity theories. The turn to nonlinear science represents not a radical break with, but rather the evolution of a worldview whose roots can be traced to US military responses to Cold War exigencies. [ABSTRACT FROM AUTHOR]

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Examines the geologic history of Crater Lake in Oregon. Characteristics of landforms; Examination of lava flow; Assessment of volcanic hazards.