In a short span of time, astronomers have taken us closer to black holes than ever with unprecedented images of the cosmic giants. Now, for the first time, scientists have seen the phenomena that takes place behind them. As part of the breakthrough, researchers witnessed captured the light from the back of a supermassive black hole 800 million light years away.
The latest breakthrough is a “key part of the puzzle to understanding” how the universe came to be, according to Stanford astrophysicist Dan Wilkins. What’s more, it appears to confirm Einstein’s theory of relativity from over a century ago.
While studying the bright flares of x-rays emanating from the black hole, a feature known as the corona, researchers also witnessed fainter flashes of light. These were the “luminous echoes” of of the flares bouncing off the gas behind the black hole. This phenomena was first predicted by Einstein in his theory of relativity published in 1916.
“Any light that goes into that black hole doesn’t come out, so we shouldn’t be able to see anything that’s behind the black hole,” Wilkins explained. “The reason we can see that is because that black hole is warping space, bending light twisting magnetic fields around itself.”
The supermassive black hole is 10 million times as massive as our Sun located in the centre of a nearby spiral galaxy called I Zwicky 1. An international group of scientists witnessed the echoes using the European Space Agency’s XMM-Newton NASA’s NuSTAR space telescopes. Their findings were published in the journal Nature.
“The color of these flashes, the color of those echoes as well as the time that they were delayed after the original flare told us that these were the echoes coming from the gas that’s hidden from our view behind the black hole,” Wilkins noted. “Some of it will shine back down onto the gas that’s falling into the black hole, this gives us really quite a unique view of this material in its final moments before it’s lost into the black hole.”
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In May, Vincent Keenan traveled from Chicago to Charlottesville, Virginia, for a wedding — his first trip out of town since the start of the pandemic.
“Hi there!” he called out to customers at a gas station where he’d stopped on his way to the airport. “How’s your day going?” he said he asked the Transportation Security Administration agent who checked his ID. “Isn’t this wonderful?” he exclaimed to guests at the wedding, most of whom were strangers.
“I was striking up conversations with people I didn’t know everywhere I went,” said Keenan, 65, who retired in December as chief executive officer of the Illinois Academy of Family Physicians. “Even if they just grunted at me, it was a great day.”
It wasn’t only close friends Keenan missed seeing during 15 months of staying home trying to avoid covid-19. It was also dozens of casual acquaintances people he ran into at social events, restaurants, church other venues.
These relationships with people we hardly know or know only superficially are called “weak ties” — a broad amorphous group that can include anyone from your neighbors or your pharmacist to members of your book group or fellow volunteers at a school.
Like Keenan, who admitted he’s an unabashed extrovert, many older adults are renewing these connections with pleasure after losing touch during the pandemic.
Casual relationships have several benefits, according to researchers who’ve studied them. These ties can cultivate a sense of belonging, provide bursts of positive energy, motivate us to engage in activities, expose us to new information opportunities — all without the emotional challenges that often attend close relationships with family friends.
Multiple studies have found that older adults with a broad array of “weak” as well as “close” ties enjoy better physical psychological well-being live longer than people with narrower, less diverse social networks. Also, older adults with broad, diverse social networks have more opportunities to develop new relationships when cherished friends or family members move away or die.
“Feeling connected to other people, not just the people who are closest to you, turns out to be incredibly important,” said Gillian Sandstrom, a senior lecturer in the department of psychology at the University of Essex in England.
Sandstrom’s research has found that people who talk to more acquaintances daily tend to be happier than people who have fewer of these interactions. Even talking to strangers makes people feel less lonely more trusting, she has discovered.
Claire Lomax, 76, of Oakland, California, who’s unmarried, has made a practice of chatting with strangers all her life. Among her greatest pleasures in recent years was volunteering at the OaklPolice Department, where she would ask patrol officers about their families or what was happening at the station.
“I never wanted a man of my own, but I like to be around them,” she explained. “So, I got to have my guy buzz without any complications, I felt recognized appreciated,” Lomax told me. Since becoming fully vaccinated, she’s volunteering in person at the police stations again — a deep source of satisfaction.
Even people who describe themselves as introverts enjoy the positivity that casual interactions can engender.
“In fact, people are more likely to have purely positive experiences with weak ties” because emotional complications are absent, said Katherine Fiori, a prominent researcher chair of the psychology department at Adelphi University in Garden City, New York.
Lynn Eggers, 75, a retired psychologist in Minneapolis, loved going to coffee shops the gym before covid hit. “In both places, you can be in a group alone,” she told me. “You can choose to talk to someone or not. But you feel you’re part of the community.”
At a light-rail station, Eggers would strike up conversations with strangers: two police officers who told her about growing up in Somalia, a working-class Texan whose daughter won a scholarship to Harvard, a young Vietnamese woman whose parents worried she was abandoning her culture.
When Eggers stopped taking public transportation for fear of covid, she missed “getting these glimpses into other ways of seeing the world.” Instead, she started chatting with neighbors in daily walks around her neighborhood — another way to feel connected.
Many people may have found that neighbors, mail carriers delivery people became more important during the pandemic — simply because they were around when others were not, said Karen Fingerman, a professor of human ecology at the University of Texas-Austin. As pandemic restrictions lift, “the key is to get out in daily life again” reengage with a variety of people activities, she recommended.
Helen Bartos, 69, a retired clinical psychologist, lives in a condominium community in Rochester, New York. “With covid, a whole group of us started getting together outside,” she told me. “We’d bring out chairs drinks, wear masks, sit around talk. It was very bonding. All of these people are neighbors; now I would call some of them friends.”
Ellie Mixter-Keller, 66, of Milwaukee, turned to social gatherings sponsored by the activity group Meetup six years ago after a divorce disrupted her life. “It was my salvation. It exposed me to a bunch of new people who I didn’t have to date or have to dinner,” she said. Now that she’s fully vaccinated, she’s busy almost every night of the week attending Meetup events informal get-togethers arranged by people she’s met.
In some cases, varying views of covid vaccines have made casual interactions more difficult. Patty Beemer, 61, of Hermosa Beach, California, used to go swing-dancing two or three times a week before the pandemic. “It’d be 20 seconds of chitchat just dance” before all those events were canceled, she said.
In the past several months, however, the swing-dance community in around Los Angeles has split, with some events requiring proof of vaccination others open to everyone.
“Before, everyone danced with everyone, without really thinking about it. Now, I don’t know if it’s going to be like that. I’m not sure how much mixing is going to happen,” Beemer said. “And that sense of shared humanity, which is so meaningful to all of us, may be harder to find.”
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It was a Sunday morning in late November when Bryan Keller hopped on a bike for a routine ride to pick up his groceries, cruising with ease in a relatively empty New York City.
The surprises came fast hard: a fall that sent his head into the pavement left him bleeding profusely in shock, a trip to an urgent care clinic for five stitches then a $1,039.50 bill.
Keller’s health insurance covered much of the cost of his visit to the CityMD clinic on Manhattan’s Lower East Side. But it didn’t cover the physician who arrived to stitch his forehead ― an out-of-network plastic surgeon with a Park Avenue office.
“The people at CityMD just said [this] sort of thing is covered as part of an emergency procedure,” said Keller, a regular cyclist who’s lived in New York City for three decades. Even in post-accident “delirium,” he said, he asked several times whether the stitches would be covered by his health insurance because it struck him as unusual that a plastic surgeon would do them.
“It really irked me that, it’s this classic thing you hear in this country all the time,” Keller said. “When you do all the right things, ask all the right questions you’re still hit with a large bill because of some weird technicality that there’s absolutely no way for you to understwhen you’re in the moment.”
Under a law Congress passed last year, many surprise medical bills will be banned starting in January. Patients with private insurance will be protected against unexpected charges for emergency out-of-network care, for treatment by out-of-network providers at in-network facilities for transport in an air ambulance. But one gray area: visits to urgent care clinics, which have proliferated in recent years as patients seek speed convenience over waiting hours at an emergency room or weeks to get a regular doctor’s appointment. There are roughly 10,500 urgent care centers in the U.S., according to the Urgent Care Association, which lobbies on their behalf.
Urgent care clinics were not explicitly addressed in the No Surprises Act, but Keller’s experience underscores patients’ predicament ― insurers often try to steer patients to urgent care away from costly emergency rooms, but individuals could still get hit with large bills in the process. The Biden administration has expressed an interest in prohibiting surprise bills in those clinics, which may treat serious conditions but not life-threatening injuries illnesses.
In July, several federal agencies issued interim regulations that largely would not protect patients from surprise urgent care bills. Regulation varies significantly across states, data is scarce on how common surprise bills are in those facilities. Before the surprise billing rules are finalized, the Department of Health Human Services three other federal agencies have asked for information on issues such as the frequency of such bills at urgent care facilities how health insurers contract with the clinics.
The current regulatory gap, if left untouched before the new law takes effect in January, is one that health care experts say could leave patients at risk.
“There’s a real interesting question about whether it should apply to the extent that people perceive these as places to go for an emergency,” said Jack Hoadley, research professor emeritus for Georgetown University’s McCourt School of Public Policy.
CityMD, which was founded by doctors in 2010 merged with the large medical practice Summit Medical Group in 2019, operates a massive chain of urgent care clinics in New York New Jersey. Most of its physicians are emergency doctors. The combined enterprise created Summit Health, which is backed by private equity with investments from well-known firms Warburg Pincus ― which acquired CityMD in 2017 ― Consonance Capital Partners.
Matt Gove, chief marketing officer of Summit Health, confirmed that the plastic surgeon who treated Keller ― Dr. Michael Wolfeld ― has an agreement with the company that allows him to see patients at certain CityMD clinics. Though he was unable to comment on the specifics of Keller’s situation, he said, CityMD’s “normal procedure” is to “make the patient aware that this is available to them that they can then make the choice as to whether or not it’s important to them to be seen by a plastic surgeon.”
“This is a patient choice,” Gove said. “We certainly don’t require that a patient be seen by Dr. Wolfeld or any other provider.”
But Keller said it was never put to him as an option. “It was framed to me as ‘This is how we do things,’” he said. “In order to have a preference I would have to know that there is an alternative.” Wolfeld did not respond to a request for comment.
Last month the Biden administration proposed prohibiting surprise bills at urgent care centers licensed to perform emergency procedures, essentially treating them as free-standing emergency rooms. Some states, like Arizona, allow urgent care centers to provide emergency services, but they then are considered free-standing ERs, a spokesperson for the state Department of Health Services said. But urgent care centers aren’t licensed as health care facilities in most states, let alone encouraged to provide emergency services, according to health care advocates that have tracked the issue have pushed for greater government oversight of the industry.
New York, where Keller lives, doesn’t consistently regulate urgent care providers, requiring licenses for some companies but not for CityMD clinics.
Regardless of what’s prescribed in state regulations, what’s considered an “emergency” versus “urgent” can vary by patient. That potentially creates confusion about whether patients would be protected from certain kinds of out-of-network bills if they show up at an urgent care facility for an acute illness or injury.
KHN also found that the urgent care clinic where Keller was treated describes several of its services as emergency care even though many are not meant to treat emergency conditions as envisioned in federal law. For example, the clinic characterizes physical exams, flu shots vaccinations as emergency medical services. Under federal law, an emergency medical condition is defined as one where the absence of immediate medical attention could seriously jeopardize a patient’s health.
Summit Health spokesperson Gove said the use of the term “emergency” is meant to be “patient-facing patient-centric, not having to do with miscategorizing or misrepresenting the nature of the services we provide.”
The provider is “just making it clear to people that when you have something you need done quickly, which you might call personally an emergency, we’re here to do that.” CityMD has never marketed itself as an emergency room designed to treat all emergency conditions, Gove said.
Lou Ellen Horwitz, CEO of the Urgent Care Association, said urgent care clinics are akin to private doctor practices rather than an emergency room or hospital facility that would be subject to broad bans on surprising billing. She said that, even as urgent care clinics grow more common, there’s “no data” to suggest consumer confusion about what they treat.
The association would oppose any federal push to classify these clinics as something akin to independent emergency departments, Horwitz said. Indeed, she said, such a move “contradicts” their very purpose: to treat non-life-threatening injuries illnesses.
“The standard practice of the industry as well is that we don’t hold ourselves out to be emergency departments,” she said. “The likelihood of this being misunderstood is very low.”
Nationwide, under the Biden administration’s interim regulations, patients needing care for nonemergencies will not be protected if treated by an out-of-network provider at an in-network urgent care facility, according to health care experts. “You don’t have protections if it turns out the doctor or the physician assistant was out of network,” Hoadley said.
A March report from Community Catalyst, a Boston-based health care advocacy organization focused on consumer issues, the National Health Law Program, a civil rights advocacy group, found that fewer than 10 states issue facility licenses for urgent care clinics. Those licenses give state officials greater leeway to set standards for care, staffing levels, inspections or price transparency, but could also make care more expensive by increasing providers’ expenses.
Without being licensed as a health care facility ― something that exists for hospitals, ambulatory surgery centers critical access hospitals ― urgent care clinics are generally treated as private physician practices subject to less regulation. “They’re really flying under the radar now in many cases,” said Lois Uttley, director of the Women’s Health Program at Community Catalyst.
Horwitz, however, said the clinics should not be lumped in with those providers because their operations are fundamentally different.
Unlike hospitals other practices that include facility fees in their charges to patients, “we don’t charge or receive payments as a facility,” she said.
In the midst of an injury, however, making such distinctions can be difficult. Keller said his motivation in going to urgent care was to get his wounds treated quickly instead of waiting hours in an ER, amid a spike in covid-19 cases that would presage the country’s deadly winter. He had also been to that particular CityMD clinic for a covid test, so he knew it accepted his insurance.
Keller hadn’t been wearing a helmet the day of his accident, caused by trying to prevent a bag of groceries from falling off his bike. With a bleeding forehead banged-up knees wrists ― Keller brushed a parked car went off the bike himself ― he was given a tetanus shot had elevated blood pressure from the shock of the accident. Still, in that moment, he thought it was odd that a plastic surgeon was being called in to give him a handful of stitches, he said.
“It sounds expensive it sounds like something optional,” he said. “I said, ‘OK, is this going to be covered?’ And they said, ‘Oh, yeah, they should be covered. He does this, he comes here all the time.’”
In New York, CityMD is not subject to facility licensure requirements because it’s considered a private physician practice, said Jeffrey Hammond, a spokesperson for the New York State Department of Health. As a result, rather than more sweeping regulations that would govern the practices of urgent care clinics, state health officials oversee individual practitioners investigate complaints related to misconduct.
On its website for the location Keller visited, CityMD advertised many of the services it provides as “emergency medical services.” They include physical exams, vaccinations, pediatric care, lab tests, X-rays, treatment for sore throats ear infections.
“Just stop by the CityMD walk-in clinic located on 138 Delancey St. between Norfolk Suffolk St, where quick, reliable, emergency care service is available 365 days a year,” the website reads.
About six weeks after receiving his stitches, Keller said, he went to the same plastic surgeon to get them removed. His health insurer, Aetna, has denied an appeal to fully cover the cost.
“It’s so clear that getting stitches for a wound, for an open bleeding wound, is an emergency procedure to the normal world,” Keller said.
As for his forehead, eight months later, Keller still has a visible scar.
The message from Big Bend Regional Medical Center was stark: The only hospital in a sparsely populated region of far West Texas notified local physicians last month that because of a nursing shortage its labor delivery unit needed to temporarily close its doors that women in labor should instead be sent to the next closest hospital — an hour’s drive away.
That is, unless the baby’s arrival appears imminent, the hospital’s unit is shut down at that point. In that case, a woman would deliver in the emergency room, said Dr. Jim Luecke, who has practiced 30-plus years in the area.
But that can be a tough call, he added. Luecke described his concerns for two patients, both nearing their due date, who had previously given birth, boosting the chance of a faster delivery. “They can go from 4 centimeters dilated to completely dilated within a few minutes,” said the family physician, who estimates he’s delivered 3,000 babies.
Some pregnant women already travel an hour a half or longer to reach the 25-bed Big Bend Regional in Alpine, said Dr. Adrian Billings, another family physician who delivers babies there. “Now to divert these ambulances at least another 60 miles away, it’s asking for more deliveries to happen en route to the hospital, potentially poor maternal or neonatal outcomes.”
Luecke can’t recall a time when the obstetrics unit at Big Bend Regional has closed.
But it’s happening in other parts of the state: Ten rural hospitals have stopped delivering babies in the past five years or so, leaving 65 out of 157 that still do, according to the Texas Organization of Rural & Community Hospitals.
Hiring retaining rural nurses has become even more challenging amid the pandemic as nurses have been recruited to work in urban covid-19 hot spots sometimes don’t return to their communities, said John Henderson, chief executive officer at TORCH. More recently, some Texas hospitals have offered signing bonuses of $10,000 or more as they jockey for nurses, he said. “Covid has caused a resetting of market rates a reshuffling of nurse staffing.”
The circumstances at Big Bend Regional, which serves a 12,000-square-mile area (about the size of Maryland), illustrates the ripple effects of potentially losing obstetric services across a broader region. The hospital, owned by Quorum Health Corp., serves a swath that extends southwest to the Mexican border includes Big Bend National Park as well as the communities of Presidio Candelaria. The nearest hospital, the 25-bed Pecos County Memorial in Fort Stockton, is 68 miles northeast of Alpine.
As of late July, Big Bend Regional’s obstetrics services remained in flux, with the unit closed for four- five-day stretches, said Billings. Physicians have been told that the unit would typically remain open only Monday morning through Thursday morning of each week until more nurses arrive, he said.
The staffing crisis highlights the need for more state national efforts to train rural nurses other clinicians, Billings added. “The big concern that I have is that, if we don’t fix this, this could be the beginning of a rural maternity care desert out here in the Big Bend.”
The hospital, which delivered 136 babies last year, said it is “working feverishly to ensure adequate staffing levels in the coming weeks,” recruiting to fill 10 nursing positions in the labor delivery unit, according to a statement to KHN. “When our hospital is on diversion for elective OB patients, we communicate in advance with nearby emergency transport services acute care providers to ensure continuity of care,” the statement said.
Kelly Jones of Alpine, who worried she was having contractions, couldn’t get anyone to pick up the phone for a few hours at Big Bend’s unit in mid-July. She decided to drop off her son at a friend’s house head to the hospital.
Jones, who is nearly full term, knew the unit had been closed a few days earlier that month but didn’t realize that closures were still occurring. “I went in said, ‘I think I’m in labor.’ They were like, ‘Well, you can’t go into labor delivery because they’re closed. So we’re going to take you to the ER.’” In the end, medical personnel determined she wasn’t going to deliver that day she went home.
Since the hospital first alerted doctors last month, the unit has been on diversion July 5-9, July 14-18 then again July 22 until Sunday, July 25, according to Billings. Efforts were being made to recruit nurses from Odessa, 150 miles away, to fill in, but the outcome was uncertain, Billings said.
Luecke scheduled an induction for one patient for July 26, when her pregnancy would be at 39 weeks — a week short of full term — the unit was scheduled to be open. “We are trying to induce them [women] on the days that they [the hospital’s unit] are open,” he said.
Jones, who is being cared for by another physician, is scheduled for induction Aug. 2, at 39 weeks. “For a while, I was not sleeping. I was really stressed. I was panicking about every scenario,” said the 30-year-old, whose pregnancy was initially considered high risk because her son had been born prematurely.
But Jones felt better once her induction date was set. And what if the baby arrives sooner the unit is closed? She’s been told to go to the ER, to be taken from there by ambulance to the local airport flown to Fort Stockton.
Malynda Richardson, director of emergency medical services for the town of Presidio, which sits along the Mexican border about 90 miles from Alpine, said its first responders transport more than two dozen women with pregnancy-related issues each year, most of them in labor, including an average of two who deliver en route. First responders, including paramedics, are not typically trained to assess a woman’s cervix for dilation, making it more difficult to gauge imminent delivery, she said.
Also, when responders drive an additional two to three hours round trip to reach Fort Stockton, that affects the Presidio community, which can reliably staff only one ambulance, Richardson said. “What happens when we do have that transport [of a woman in labor] have to go to Fort Stockton then we have somebody else down here having a heart attack we don’t have an ambulance available?”
Rural obstetrics units require far more nurses than doctors to remain open, so diverting women elsewhere in the short term makes sense, said Dr. Tony Ogburn, who chairs the department of obstetrics gynecology at the University of Texas Rio Grande Valley School of Medicine. “If you don’t have trained nurses there, it doesn’t matter if you have a physician that can do a C-section or do a delivery; you can’t take care of those patients safely,” he said.
Registered nurses who work in labor delivery have completed specialized training, such as how to read a fetal heart monitor, so a nurse from the ER or another hospital unit can’t easily step in, Billings said. “It’s kind of like having a small football team or a small soccer team not being able to pull from the bench,” he said.
Billings said he’s reached out to Dr. Michael Galloway, who chairs the department of obstetrics gynecology at Texas Tech University Health Sciences Center in Odessa has been helping coordinate efforts to recruit nurses from that city. But even if Odessa nurses agree to pick up some shifts at Big Bend Regional, they are likely a stopgap solution, said Billings, who questions how long they’d be willing to work so far away from home.
Luecke believes Big Bend Regional administrators are doing everything they can to improve nurse staffing. But, like Billings, he’s worried that these July temporary closures could become longer-term.
“We are hoping August will be a different situation,” Luecke said. “But it’s pretty iffy right now.”
Square has announced that it plans to pay $29 billion in stock for Afterpay, an Australian service that lets you pay for purchases over time with no interest, The Verge has reported. Square, led by Twitter co-founder Jack Dorsey, has already purchased a majority stake in Tidal launched a new Bitcoin business in 2021.
In a press release, Square called Afterpay “the pioneering global ‘buy now, pay later’ (BNPL) platform.” Afterpay notes that it has over 16 million customers worldwide services nearly 100,000 resellers across retail markets like “fashion, homewares, beauty, sporting goods more.”
“The addition of Afterpay to Cash App will strengthen our growing networks of consumers around the world, while supporting consumers with flexible, responsible payment options,” said Square’s Brian Grassadonia. “Afterpay will help deepen reinforce the connections between our Cash App Seller ecosystems, accelerate our ability to offer a rich suite of commerce capabilities to Cash App customers.”
Afterpay, like other increasingly popular BNPL services (including Affirm, Klarna Uplift), allows customers to pay over time without interest. To make money, they charge retailers a fee (4 to 6 percent), promising to connect them with a desirable demographic assume all financial risk. In Square’s press release, Afterpay also said it can help “drive repeat purchases [and] increase average transaction sizes.”
One of the world’s largest retailers, Apple, is reportedly planning to offer its own buy now, pay later type program directly to consumers. Much like PayPal’s “Pay in 4” service, “Apple Pay in 4” would allow Apple Wallet users to stretch purchases out to four payments, interest-free. Square’s purchase of Afterpay, meanwhile, is expected to close in the first quarter of 2022.
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