Digital Commons Network^™

A Comparison Of Chief Complaints, Specific Diagnoses, And Demographics Of Pediatric Urgent Care Visits Before And During The Covid-19 Pandemic: A Retrospective Study, Zaharoula A. Viennas, Julie Martin, Benjamin Klick, Tammy Speerhas, Turaj Vazifedan, Danielle Millspaugh, Jennifer Ferris, Margret Bedle, Lauren Paluch, Theresa Guins

Ellmer School of Nursing Faculty Publications

There was an increased incidence of pediatric patients who presented with injuries caused by falls not related to sports or other recreational activities, as well as for animal bites, during the early pandemic period of April 2020. Education of parents and caregivers of young children is warranted to raise awareness of the even greater potential for falls and animal bites when children are confined at home for longer than typical periods of time, as occurred with the stay-at-home government orders during the initial period of the COVID-19 pandemic.

Retinal Alpha-Synuclein Accumulation Correlates With Retinal Dysfunction And Structural Thinning In The A53t Mouse Model Of Parkinson’S Disease, Katie K N Tran, Vickie H Y Wong, Anh Hoang, David I Finkelstein, Bang V Bui, Christine T O Nguyen

Faculty, Staff and Student Publications

Abnormal alpha-synuclein (α-SYN) protein deposition has long been recognized as one of the pathological hallmarks of Parkinson's disease's (PD). This study considers the potential utility of PD retinal biomarkers by investigating retinal changes in a well characterized PD model of α-SYN overexpression and how these correspond to the presence of retinal α-SYN. Transgenic A53T homozygous (HOM) mice overexpressing human α-SYN and wildtype (WT) control littermates were assessed at 4, 6, and 14  months of age (male and female,

Resveratrol Rescues Cutaneous Radiation-Induced Dna Damage Via A Novel Ampk/Sirt7/Hmgb1 Regulatory Axis, Yi Jin, Xingyuan Liu, Xiaoting Liang, Jiabin Liu, Jieyu Liu, Zonglin Han, Qianxin Lu, Ke Wang, Bingyao Meng, Chunting Zhang, Minna Xu, Jian Guan, Li Ma, Liang Zhou

Faculty, Staff and Student Publications

Cutaneous radiation injury (CRI) interrupts the scheduled process of radiotherapy and even compromises the life quality of patients. However, the current clinical options for alleviating CRI are relatively limited. Resveratrol (RSV) has been shown to be a promising protective agent against CRI; yet the mechanisms of RSV enhancing radioresistance were not fully elucidated and limited its clinical application. In this study, we demonstrate RSV promotes cutaneous radioresistance mainly through SIRT7. During ionizing radiation (IR) treatment, RSV indirectly phosphorylates and activates SIRT7 through AMPK, which is critical for maintaining the genome stability of keratinocytes. Immunoprecipitation and mass spectrometry identified HMGB1 to …

Il-8 Produced Via Bidirectional Communication Between Prostate Cancer And M2 Macrophages As A Potential Diagnostic And Prognostic Biomarker, Huihui Fan, Zheng Tang, Yaling Tian, Qingsong Lv, Fangyin Zeng

Faculty, Staff and Student Publications

PURPOSE: Owing to the mortality associated with metastatic prostate cancer and the shortcomings of the current parameters in predicting the disease prognosis, we require the identification of viable biomarkers, which would help in the diagnosis and prognosis of the disease. We aimed to determine whether the interleukin-8 level in the tumor microenvironment could serve as a potential clinical diagnostic marker and prognostic factor for prostate cancer.

METHODS: The migration assay of prostate cancer cells was performed in an in vitro co-culture model. Cell lines PC3 and DU145 were divided into two groups and co-cultured with M0 and M2 macrophages, respectively. …

Exaptation And Evolutionary Adaptation In Nociceptor Mechanisms Driving Persistent Pain, Edgar T Walters

Faculty, Staff and Student Publications

Background: Several evolutionary explanations have been proposed for why chronic pain is a major clinical problem. One is that some mechanisms important for driving chronic pain, while maladaptive for modern humans, were adaptive because they enhanced survival. Evidence is reviewed for persistent nociceptor hyperactivity (PNH), known to promote chronic pain in rodents and humans, being an evolutionarily adaptive response to significant bodily injury, and primitive molecular mechanisms related to cellular injury and stress being exapted (co-opted or repurposed) to drive PNH and consequent pain.

Summary: PNH in a snail (Aplysia californica), squid (Doryteuthis pealeii), fruit fly (Drosophila melanogaster), mice, rats, …

The Involvement Of Kynurenine Pathway In Neurodegenerative Diseases, Lais B Martins, Ana L M Silveira, Antonio L Teixeira

Faculty, Staff and Student Publications

BACKGROUND: A growing body of evidence has shown the involvement of the kynurenine pathway (KP), the primary route of tryptophan (TRP) catabolism, in the pathophysiology of neuropsychiatric disorders.

OBJECTIVE: The study aims to provide a comprehensive and critical overview of the clinical evidence on the KP involvement in the pathophysiology of Alzheimer's disease (AD) and Parkinson's disease (PD), discussing therapeutic opportunities.

METHODS: We searched for studies investigating KP metabolites in human subjects with AD and/or PD.

RESULTS: Postmortem studies showed altered levels of KP metabolites in the brain of AD and PD patients compared with controls. Cross-sectional studies have reported …

Role Of Microrna-34a In Blood-Brain Barrier Permeability And Mitochondrial Function In Ischemic Stroke, Cole T Payne, Sidra Tabassum, Silin Wu, Heng Hu, Aaron M Gusdon, Huimahn A Choi, Xuefang S Ren

Faculty, Staff and Student Publications

Over the past decade, there has been an uptick in the number of studies conducting research on the role of microRNA (miRNA) molecules in stroke. Among these molecules, miR-34a has emerged as a significant player, as its levels have been observed to exhibit a substantial rise following ischemic events. Elevated levels of miR-34a have been found to have multiple effects, including the modulation of inflammatory molecules involved in the post-stroke recovery process, as well as negative effects on the blood-brain barrier (BBB) permeability. Interestingly, the increase of miR-34a appears to increase BBB permeability post stroke, through the negative effect on …

Antimicrobial Activity Of Plasma Rich In Platelets (Prp) On The Ocular Microbiota Of Healthy Horses From Minas Gerais, Luis E C Torres, Camilo O Florez, Jéssica G Oliveira, Giovanna D Vieira, Ilza S Ribeiro, Kelly M Keller, Fabíola O P Leme, Priscila Fantini, Renata P A Maranhão

Faculty, Staff and Student Publications

In equine ophthalmology, ulcerative keratitis is among the most common conditions and, in general, arises as a consequence of some trauma suffered. Secondarily, subsequent contamination by pathogenic or resident bacteria of the horse's ocular microbiota may have undesirable consequences. Under physiological conditions, the normal microbiota coexists with the immune status of the host, serving as a barrier, ensuring the health of the ocular surface, and inhibiting the proliferation of pathogens. However, in the imbalance of immune barriers, the normal microbiota can become pathogenic and lead to infection, acting as an opportunistic agent. The present study aims to demonstrate the antimicrobial …

Isoprenylation Inhibition Significantly Reduces Ige Mediated Mast Cell Function And Allergic Disease, Jordan Dailey

Theses and Dissertations

Allergic disease is the 6^th leading cause of chronic illness in the US and accounts for billions of dollars in healthcare annually. Mast cells are tissue resident innate immune cells linked to allergic disease and activated by IgE and other ligands. Upon activation, they release histamine, cytokines, chemokines, proteases, and lipid mediators evoking allergic symptoms. New ways of targeting mast cells could greatly benefit allergic disease therapy. Previous findings supported repurposing statin drugs, such as Fluvastatin, as a therapeutic treatment of allergic disease reduced allergic symptoms in vitro and in vivo. We found that Fluvastatin suppressed IgE-mediated mast cell …

Assessing Drug Development Proporties Of Antithrombotic And Anti - Cancer Agents, Elsamani I. Abdelfadiel

Theses and Dissertations

The current GAG anticoagulants such as heparin, heparin derivatives, and vitamin K antagonists, such as warfarin continue to be the backbone of anticoagulant therapy. These drugs act through an indirect mechanism to convey inhibition of several coagulation enzymes. However, xv their use leads to several serious adverse effects, such as excessive bleeding risk and unpredictability of patient response. Regardless of their clinical achievement, every individual agent is accompanied by several side effects, particularly major/minor bleeding, thrombocytopenia, drug-food or drug-drug interactions, or absence of antidote. Of all these side effects, bleeding, and a lack of an effective antidote to reverse excessive …

Molecular Mechanisms Of Prdm16 As A Tumor Suppressor In Pancreatic Ductal Adenocarcinoma, Eric Hurwitz

Theses and Dissertations

The transcription factor Prdm16 functions as a potent suppressor of transforming growth factor-beta (TGF-b) signaling, whose inactivation is deemed essential to the progression of pancreatic ductal adenocarcinoma (PDAC). Using the Kras^G12D-based mouse model of human PDAC, we surprisingly found that ablating Prdm16 did not block but instead accelerated PDAC formation and progression, suggesting that Prdm16 might function as a tumor suppressor in this malignancy. Subsequent genetic experiments showed that ablating Prdm16 along with Smad4 resulted in a shift from a well-differentiated and confined neoplasm to a highly aggressive and metastatic disease, which was associated with a striking deviation …

A Standardized Pipeline For Isolation And Assembly Of Genomes From Symbiotic Bacteria In Whole Louse Genomic Sequence Data., Mohammad Mikail I. Bala

Theses and Dissertations

Many insects are known to harbour intracellular and heritable bacteria (endosymbionts), which provide their hosts with adaptive traits. Whole insect gDNA shotgun sequencing projects often sequence the genome of endosymbiont, in addition to the insect’s genome. There are approximately 600 whole genome shotgun libraries from insects available on the public repository (NCBI), which can be mined to obtain endosymbiont genomes. The assembly and annotation of endosymbiont genomes can contribute towards the exploration of their role as obligate symbiotic partners. However, de novo assembly of an endosymbiont genome, continues to be challenging, when the host and/or enteric bacterial gDNA is present …

3,3′-Diindolylmethane Augments 5-Fluorouracil-Inducedgrowth Suppression In Gastric Cancer Cells Through Suppression Of The Akt/Gsk-3Β And Wnt/Beta-Catenin, Cong Shan Li, Thi Van Nguyen, Ok Hee Chai, Byung Hyun Park, Ju-Seog Lee, Soo Mi Kim

Faculty, Staff and Student Publications

Gastric cancer (GC) is one of the most lethal cancers in South Korea, and it is a cancer of concern worldwide. 5-fluorouracil (5-Fu) is commonly used as the first-line therapy for advanced GC; however, its side effects often limit the dosage range and impair patients' quality of life. Due to the limitations of current chemotherapy, new anticancer therapies are urgently needed. 3,3'-diindolylmethane (DIM) has been reported to have the ability to protect against various types of cancer. Our study aimed to elucidate the anticancer effect of DIM in GC when treated with the chemotherapeutic agent 5-Fu. In our results, combined …

Exosomal Lipid Biomarkers Of Oligodendrocyte Pathology To Predict Scoliosis In Children With Cerebral Palsy, Nune Darbinian, Emily C Sparks, Armine Darbinyan, Nana Merabova, Tamara Tatevosian-Geller, Katie Calaku, Sarah Bachman, Huaqing Zhao, Shohreh Amini, Laura Goetzl, Solomon P Samuel, Amer Samdani, Michael E Selzer

Faculty, Staff and Student Publications

INTRODUCTION: Cerebral Palsy (CP), the most common cause of disability in children, is phenotypically heterogeneous. Approximately 20% of cases develop severe scoliosis. A pathological hallmark of CP is periventricular leukomalacia (PVL), which is due to dysmyelination, suggesting the possibility of a lipidomic abnormality. Risk factors for CP include perinatal hypoxia, prematurity, multiple gestation, ischemia, infection, and maternal alcohol consumption. There is evidence for low serum levels of omega-3 (ω-3) fatty acids in CP patients, and separately in idiopathic scoliosis. Many effects of free fatty acids (FFAs) are mediated via specific G protein-coupled free fatty acid receptors (FFARs), which play essential …

The Proteasome: A Key Modulator Of Nervous System Function, Brain Aging, And Neurodegenerative Disease, Kanisa Davidson, Andrew M Pickering

Faculty, Staff and Student Publications

The proteasome is a large multi-subunit protease responsible for the degradation and removal of oxidized, misfolded, and polyubiquitinated proteins. The proteasome plays critical roles in nervous system processes. This includes maintenance of cellular homeostasis in neurons. It also includes roles in long-term potentiation via modulation of CREB signaling. The proteasome also possesses roles in promoting dendritic spine growth driven by proteasome localization to the dendritic spines in an NMDA/CaMKIIα dependent manner. Proteasome inhibition experiments in varied organisms has been shown to impact memory, consolidation, recollection and extinction. The proteasome has been further shown to impact circadian rhythm through modulation of …

Translating Energy Balance Research From The Bench To The Clinic To The Community: Parallel Animal-Human Studies In Cancer, Miriam B Garcia, Keri L Schadler, Joya Chandra, Steven K Clinton, Kerry S Courneya, Zobeida Cruz-Monserrate, Carrie R Daniel, Andrew J Dannenberg, Wendy Demark-Wahnefried, Mark W Dewhirst, Carol J Fabian, Stephen D Hursting, Melinda L Irwin, Neil M Iyengar, Jennifer L Mcquade, Kathryn H Schmitz, Karen Basen-Engquist

Faculty, Staff and Student Publications

Advances in energy balance and cancer research to date have largely occurred in siloed work in rodents or patients. However, substantial benefit can be derived from parallel studies in which animal models inform the design of clinical and population studies or in which clinical observations become the basis for animal studies. The conference Translating Energy Balance from Bench to Communities: Application of Parallel Animal-Human Studies in Cancer, held in July 2021, convened investigators from basic, translational/clinical, and population science research to share knowledge, examples of successful parallel studies, and strong research to move the field of energy balance and cancer …

Documenting Range Expansion Of Two Invasive Tick (Acari:Ixodidae) Species In Eastern South Dakota, Braden Wojahn

Dissertations and Theses

This project documents the expanded zoogeographic ranges of the blacklegged tick (Ixodes scapularis) and lone star tick (Amblyomma americanum) within eastern South Dakota. Ticks are important when considering a “One Health” approach, as many species are competent vectors of zoonotic pathogens causing human diseases and conditions such as Lyme disease, tularemia, rickettsia, and alpha gal syndrome. The research involved constitutes two steps. First, tick surveillance was conducted in eastern counties of South Dakota, spanning March 2021 through August 2022. Surveillance took place along edge habitat at recreation areas, state and public parks, wildlife management areas and refuges, and other natural …

Clinical Insights Into Small Cell Lung Cancer: Tumor Heterogeneity, Diagnosis, Therapy, And Future Directions, Zsolt Megyesfalvi, Carl M Gay, Helmut Popper, Robert Pirker, Gyula Ostoros, Simon Heeke, Christian Lang, Konrad Hoetzenecker, Anna Schwendenwein, Kristiina Boettiger, Paul A Bunn, Ferenc Renyi-Vamos, Karin Schelch, Helmut Prosch, Lauren A Byers, Fred R Hirsch, Balazs Dome

Faculty, Staff and Student Publications

Small cell lung cancer (SCLC) is characterized by rapid growth and high metastatic capacity. It has strong epidemiologic and biologic links to tobacco carcinogens. Although the majority of SCLCs exhibit neuroendocrine features, an important subset of tumors lacks these properties. Genomic profiling of SCLC reveals genetic instability, almost universal inactivation of the tumor suppressor genes TP53 and RB1, and a high mutation burden. Because of early metastasis, only a small fraction of patients are amenable to curative-intent lung resection, and these individuals require adjuvant platinum-etoposide chemotherapy. Therefore, the vast majority of patients are currently being treated with chemoradiation with or …

Pre-Epithelialized Cryopreserved Tracheal Allograft For Neo-Trachea Flap Engineering, Ning Zeng, Youbai Chen, Yewen Wu, Mengqing Zang, Rene D Largo, Edward I Chang, Mark V Schaverien, Peirong Yu, Qixu Zhang

Faculty, Staff and Student Publications

Background: Tracheal reconstruction presents a challenge because of the difficulty in maintaining the rigidity of the trachea to ensure an open lumen and in achieving an intact luminal lining that secretes mucus to protect against infection.

Methods: On the basis of the finding that tracheal cartilage has immune privilege, researchers recently started subjecting tracheal allografts to "partial decellularization" (in which only the epithelium and its antigenicity are removed), rather than complete decellularization, to maintain the tracheal cartilage as an ideal scaffold for tracheal tissue engineering and reconstruction. In the present study, we combined a bioengineering approach and a cryopreservation technique …

Chd1, A Multifaceted Epigenetic Remodeler In Prostate Cancer, Haoyan Li, Loraine Gigi, Di Zhao

Faculty, Staff and Student Publications

Chromatin remodeling proteins contribute to DNA replication, transcription, repair, and recombination. The chromodomain helicase DNA-binding (CHD) family of remodelers plays crucial roles in embryonic development, hematopoiesis, and neurogenesis. As the founding member, CHD1 is capable of assembling nucleosomes, remodeling chromatin structure, and regulating gene transcription. Dysregulation of CHD1 at genetic, epigenetic, and post-translational levels is common in malignancies and other human diseases. Through interacting with different genetic alterations, CHD1 possesses the capabilities to exert oncogenic or tumor-suppressive functions in context-dependent manners. In this Review, we summarize the biochemical properties and dysregulation of CHD1 in cancer cells, and then discuss CHD1's …

Editorial: Prion-Like Transmission Of Pathogenic Proteins In Neurodegenerative Diseases: Structural And Molecular Bases, Victor Banerjee, Fei Wang, Daniela Sarnataro, Claudio Soto

Faculty, Staff and Student Publications

No abstract provided.

Targeting T Cell Checkpoints 41bb And Lag3 And Myeloid Cell Cxcr1/Cxcr2 Results In Antitumor Immunity And Durable Response In Pancreatic Cancer, Pat Gulhati, Aislyn Schalck, Shan Jiang, Xiaoying Shang, Chang-Jiun Wu, Pingping Hou, Sharia Hernandez Ruiz, Luisa Solis Soto, Edwin Parra, Haoqiang Ying, Jincheng Han, Prasenjit Dey, Jun Li, Pingna Deng, Emi Sei, Dean Y Maeda, John A Zebala, Denise J Spring, Michael Kim, Huamin Wang, Anirban Maitra, Dirk Moore, Karen Clise-Dwyer, Y Alan Wang, Nicholas E Navin, Ronald A Depinho

Faculty, Staff and Student Publications

Pancreatic ductal adenocarcinoma (PDAC) is considered non-immunogenic, with trials showing its recalcitrance to PD1 and CTLA4 immune checkpoint therapies (ICTs). Here, we sought to systematically characterize the mechanisms underlying de novo ICT resistance and to identify effective therapeutic options for PDAC. We report that agonist 41BB and antagonist LAG3 ICT alone and in combination, increased survival and antitumor immunity, characterized by modulating T cell subsets with antitumor activity, increased T cell clonality and diversification, decreased immunosuppressive myeloid cells and increased antigen presentation/decreased immunosuppressive capability of myeloid cells. Translational analyses confirmed the expression of 41BB and LAG3 in human PDAC. Since …

La Radical Imperfección Del Mundo: El Crimen Perfecto De Jean Baudrillard Y El Crimen Ferpecto De Alex De La Iglesia, Maria A. Gomez

The Coastal Review

Le parfait crime (1995) by Jean Baudrillard and Crimen ferpecto (2004) by the Basque director Alex de la Iglesia are two works that not only have in common almost identical titles. They both reflect on how in consumer societies, an imperfect real world is substituted for an illusory hyperreality in which the distinction between subject and object has disappeared. While Baudrillard explains how the denial of a transcendent reality in contemporary society is “a perfect crime” that destroys the real, Alex de la Iglesia uses black humor and a mix of genres (mainly grotesque comedy and thriller) to show the …

Targeting Immunosuppressive Ly6c+ Classical Monocytes Reverses Anti-Pd-1/Ctla-4 Immunotherapy Resistance, B Leticia Rodriguez, Limo Chen, Yanli Li, Shucheng Miao, David H Peng, Jared J Fradette, Lixia Diao, Jessica M Konen, Frank R Rojas Alvarez, Luisa M Solis, Xiaohui Yi, Aparna Padhye, Laura A Gibson, Joshua K Ochieng, Xiaofei Zhou, Jing Wang, Don L Gibbons

Faculty, Staff and Student Publications

Introduction: Despite significant clinical advancement with the use of immune checkpoint blockade (ICB) in non-small cell lung cancer (NSCLC) there are still a major subset of patients that develop adaptive/acquired resistance. Understanding resistance mechanisms to ICB is critical to developing new therapeutic strategies and improving patient survival. The dynamic nature of the tumor microenvironment and the mutational load driving tumor immunogenicity limit the efficacy to ICB. Recent studies indicate that myeloid cells are drivers of ICB resistance. In this study we sought to understand which immune cells were contributing to resistance and if we could modify them in a way …

The Use Of Distraction Techniques During Injection In Pediatric Patients, Sara Mollner

Master of Science in Nursing Family Nurse Practitioner

Do distraction techniques provide adequate pain management in the pediatric population? If so, what is the importance of this topic? Children can develop negative emotional connections to healthcare workers and procedures if they are constantly put through painful experiences. Making these experiences less painful can ensure better healthcare for the future.

Updated Virophage Taxonomy And Distinction From Polinton-Like Viruses, Simon Roux, Matthias G. Fischer, Thomas Hackl, Laura A. Katz, Frederik Schulz, Natalya Yutin

Biological Sciences: Faculty Publications

Virophages are small dsDNA viruses that hijack the machinery of giant viruses during the co-infection of a protist (i.e., microeukaryotic) host and represent an exceptional case of “hyperparasitism” in the viral world. While only a handful of virophages have been isolated, a vast diversity of virophage-like sequences have been uncovered from diverse metagenomes. Their wide ecological distribution, idiosyncratic infection and replication strategy, ability to integrate into protist and giant virus genomes and potential role in antiviral defense have made virophages a topic of broad interest. However, one limitation for further studies is the lack of clarity regarding the nomenclature and …

Post-Soviet History Of Jehovah's Witnesses In Ukraine: From A Closed Sect To An Open Denomination, Vita Tytarenko, Liudmyla Fylypovych

Occasional Papers on Religion in Eastern Europe

This article considers the changes that have taken place in the Jehovah's Witnesses (JW) from the time of the USSR to today, when believers and their communities are having to fit into new historical circumstances. In peacetime JW occupied a relatively insignificant niche in the structure of religious life of Ukraine, overcoming the wary and sometimes openly negative attitude of the state, society, and other religious communities, formed by the Soviet regime. After 2014 JW are more and more confidently declaring their presence in Ukrainian society. Those who survived persecution and deportation during the Soviet era are regaining their rights …

Social Mission Of Orthodox Churches In The Conditions Of 2022 Russian Invasion Of Ukraine, Vitalii Turenko

Occasional Papers on Religion in Eastern Europe

The article reveals the peculiarities and specifics of the implementation of the social mission of key domestic Orthodox denominations in the context of Russia's full-scale war against Ukraine. The key aspects of providing assistance and support to the Orthodox Church of Ukraine (hereafter OCU) and Ukrainian Orthodox Church (Hereafter UOC) for both the military and the civilian population were analyzed. Differences in the provision of aid between the Orthodox churches were revealed: if the former helps through volunteers by providing and purchasing weapons, the latter is limited to the purchase of transport, the provision of basic necessities and food and …

Assistance Given To The Ukrainian Refugees By The Polish People After Russian Invasion Of Ukraine On February 24, 2022, Elžbieta Pakszys

Occasional Papers on Religion in Eastern Europe

My task here is to relate the ways in which the Polish population helps Ukrainian refugees since the beginning of the Russian aggression. Who are these refugees? How do they obtain help? I also want to think about the motivations for such spontaneous willingness to help. What are the presumed reasons for it, and what are the true ones? What is the impact of events from the past on the present situation? Also – whom and why are Poles helping less willingly, namely the so-called ‘problem of refugees’ from behind the Byelorussian boarder.

Analyzing Residential Curbside Collection For Food Waste In Humboldt County, Yvette Lindler

Cal Poly Humboldt theses and projects

The most prevalent material in the California landfill-destined solid waste stream is food. Food waste is not only an economic and social concern, but a significant environmental challenge as well. Most food waste is disposed of in landfills, where it anaerobically decomposes and releases methane, an extremely potent greenhouse gas and driver of climate change. Policies passed in California, including AB 1826 and SB 1383, aim to implement organic waste recycling programs and reduce methane emissions by diverting organic waste from landfills. The technology to process this food waste exists, but these facilities are limited or nonexistent in rural areas …