Wiener algebra for the quaternions

We define and study the counterpart of the Wiener algebra in the quaternionic setting, both for the discrete and continuous case. We prove a Wiener-L\'evy type theorem and a factorization theorem. We give applications to Toeplitz and Wiener-Hopf operators

Covid-19 and Social Determinants of Health: Medicaid Managed Care Organizations’ Experiences With Addressing Member Social Needs

Background The significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined. Aim The purpose of this study was to describe MMCOs’ experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic. Methods The study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis. Results Four themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners. Conclusion Among MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint

Georgia\u27s Critical Access Hospitals: Financial Performance and Process Improvement

Background: Georgia’s Critical Access Hospitals (CAH) are in crisis. Within the last 2 years, four CAHs have closed their doors due to failed financial and operational performance. Evidence points to the risk that several more are on the brink of closure. CAH closures have far-reaching impact on residents. Negative impacts include the extra distance that patients must travel to seek care, the displacement of health professionals and the unravelling of the entire fabric of the communities these hospitals serve. We hope to help participants understand the financial and operational challenges of CAHs, and to identify realistic strategies to enhance the resilience of these hospitals. Methods: The Georgia Southern team worked with a cohort of CAHs across the state of Georgia to identify financial and operational best practices. Year 1 of this project focused on data collection, analysis and benchmarking. Year 2 is currently focused on performance improvement through Lean Six Sigma. Results: CAHs face financial constraints due to factors such as low volume, declining market share, unfavorable payer mix, challenges relating to collections, and difficulties in recruiting providers. CAHs in Georgia performed more poorly on the financial indicators assessed, in comparison to respective national medians. Many CAHs in our cohort are better organized to deal with crises – utilizing strong executive and bureaucratic structures – than to pursue ongoing improvement through employee empowerment and a process focus. Conclusions: Improvements in the operational and financial management practices of Georgia’s CAHs may significantly improve performance. Evidence-based strategies for operational and financial improvement are vital to sustainability. Opportunities exist for collaboration between public health systems and rural hospitals, including CAHs in assuring healthcare access for rural populations

Operational and Financial Performance of Georgia\u27s Critical Access Hospitals

Background: Georgia’s Critical Access Hospitals (CAHs) face increasingly complex threats to financial sustainability, as demonstrated by the disproportionally high number of closures in comparison to other states in the nation. Methods: Financial performance measures (including profitability, revenue, liquidity, debt, utilization, and productivity), site visits, key personnel interviews, and a revenue cycle management assessment were used to assess the strategic landscape of CAHs in Georgia, analyze financial and operational performance, and provide recommendations. Results: For CAHs in Georgia, financial and operating performance indicators, interviews, and assessments depict a challenging operating environment, but opportunities for improvement exist through implementation of a Lean Six Sigma program and improved benchmarking processes. Conclusions: Georgia’s CAHs operate in a challenging environment, but operational improvement strategies (such as a Lean Six Sigma program) and benchmarking directed towards business processes, including revenue cycle management, provide opportunities for sustainability in the future. Key words: Critical Access Hospital, financial performance, Process Improvement, LEAN Six Sigma, rural hospita

Clocking the Lyme Spirochete

In order to clear the body of infecting spirochetes, phagocytic cells must be able to get hold of them. In real-time phase-contrast videomicroscopy we were able to measure the speed of Borrelia burgdorferi (Bb), the Lyme spirochete, moving back and forth across a platelet to which it was tethered. Its mean crossing speed was 1,636 µm/min (N = 28), maximum, 2800 µm/min (N = 3). This is the fastest speed recorded for a spirochete, and upward of two orders of magnitude above the speed of a human neutrophil, the fastest cell in the body. This alacrity and its interpretation, in an organism with bidirectional motor capacity, may well contribute to difficulties in spirochete clearance by the host

Racial Disparities in Emergency General Surgery: Do Differences in Outcomes Persist Among Universally Insured Military Patients?

Research Objective: Described as one of the most serious health problems affecting the nation, racial disparities are estimated to account for \u3e83,000 deaths, \u3e$57 billion per year. They have been identified in multiple surgical settings, including differences in outcomes by race among emergency general surgery(EGS) patients. As many minority patients are uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30/90/180day outcomes exist within a universally-insured population of military/civilian-dependent EGS patients and whether differences in outcomes differentially persist in care received at military-vs-civilian hospitals and among sponsors who are enlisted-service members-vs-officers. It also considered longer-term outcomes of care. Study Design: Risk-adjusted survival analyses using Cox proportional-hazards models assessed race-based differences in mortality, major morbidity, and readmission from index-hospital admission (discharge for readmission) through 30/90/180days. Models accounted for hospital clustering and possible biases associated with missing race (reweighted-estimating equations). Sub-analyses considered effects restricted to operative interventions, stratified by 24 EGS-diagnostic categories defined by the American Association for the Surgery of Trauma(AAST), and effect modification related to rank (SES-proxy: officers-vs-enlisted-sponsors) and military-vs-civilian-hospital care. Population Studied: Five years of national TRICARE Prime/Prime-plus data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18y) with primary EGS conditions, defined by the AAST. Patients who did not have an index admission between 01/01/2006-01/07/2010 (minimum 180days follow-up) or who were not continuously enrolled in TRICARE for 180days were excluded. Non-surviving patients were retained while they survived. Principal Findings: A total of 101,011 patients were included: 73.5% White, 14.5% Black, 4.4% Asian, 7.7% other. Risk-adjusted analyses reported equivalent-or-better mortality and readmission outcomes among minority patients at 30/90/180days—even when restricted to civilian hospitals where studies suggest that EGS disparities are found. Readmissions within military hospitals were lower among minority patients. Major morbidity was higher among Black versus White patients (HR[95%CI]): 30day-1.23[1.13-1.35], 90day-1.18[1.09-1.28], 180day-1.15[1.07-1.24]—a finding driven by appendiceal disorders (HR:1.69-1.70). No other diagnostic category-based HR was significant. When considered by rank, significant effects were isolated to enlisted-service members. However, given the relatively small number of patients who were (dependents of) officers, it is difficult to determine whether rank-based findings are a result of social determinants or influenced by the limited number of minority patients. Conclusions: The first of its kind to examine racial disparities in longer-term outcomes of EGS care, this longitudinal analysis of military patients demonstrated apparent mitigation of racial disparities within a universally-insured health system when compared to the overall US health system. Efforts to explain findings based on consideration of care provided in military-vs-civilian hospitals, among specific EGS-diagnostic categories, and based on sponsor rank revealed modification of the association between race and outcomes to some extent for all three. Implications for Policy or Practice: The contrast between results for universally-insured military/civilian-dependent patients and reported disparities among all US civilian patients merits consideration. The data speak to the importance of insurance-coverage in the development of disparities interventions nationwide and will help to inform policy within the DoD

The Complete Genome Sequence of ‘Candidatus Liberibacter solanacearum’, the Bacterium Associated with Potato Zebra Chip Disease

Zebra Chip (ZC) is an emerging plant disease that causes aboveground decline of potato shoots and generally results in unusable tubers. This disease has led to multi-million dollar losses for growers in the central and western United States over the past decade and impacts the livelihood of potato farmers in Mexico and New Zealand. ZC is associated with ‘Candidatus Liberibacter solanacearum’, a fastidious alpha-proteobacterium that is transmitted by a phloem-feeding psyllid vector, Bactericera cockerelli Sulc. Research on this disease has been hampered by a lack of robust culture methods and paucity of genome sequence information for ‘Ca. L. solanacearum’. Here we present the sequence of the 1.26 Mbp metagenome of ‘Ca. L. solanacearum’, based on DNA isolated from potato psyllids. The coding inventory of the ‘Ca. L. solanacearum’ genome was analyzed and compared to related Rhizobiaceae to better understand ‘Ca. L. solanacearum’ physiology and identify potential targets to develop improved treatment strategies. This analysis revealed a number of unique transporters and pathways, all potentially contributing to ZC pathogenesis. Some of these factors may have been acquired through horizontal gene transfer. Taxonomically, ‘Ca. L. solanacearum’ is related to ‘Ca. L. asiaticus’, a suspected causative agent of citrus huanglongbing, yet many genome rearrangements and several gene gains/losses are evident when comparing these two Liberibacter. species. Relative to ‘Ca. L. asiaticus’, ‘Ca. L. solanacearum’ probably has reduced capacity for nucleic acid modification, increased amino acid and vitamin biosynthesis functionalities, and gained a high-affinity iron transport system characteristic of several pathogenic microbes

A Toxin–Antitoxin System Promotes the Maintenance of an Integrative Conjugative Element

SXT is an integrative and conjugative element (ICE) that confers resistance to multiple antibiotics upon many clinical isolates of Vibrio cholerae. In most cells, this ∼100 Kb element is integrated into the host genome in a site-specific fashion; however, SXT can excise to form an extrachromosomal circle that is thought to be the substrate for conjugative transfer. Daughter cells lacking SXT can theoretically arise if cell division occurs prior to the element's reintegration. Even though ∼2% of SXT-bearing cells contain the excised form of the ICE, cells that have lost the element have not been detected. Here, using a positive selection-based system, SXT loss was detected rarely at a frequency of ∼1×10−7. As expected, excision appears necessary for loss, and factors influencing the frequency of excision altered the frequency of SXT loss. We screened the entire 100 kb SXT genome and identified two genes within SXT, now designated mosA and mosT (for maintenance of SXT Antitoxin and Toxin), that promote SXT stability. These two genes, which lack similarity to any previously characterized genes, encode a novel toxin-antitoxin pair; expression of mosT greatly impaired cell growth and mosA expression ameliorated MosT toxicity. Factors that promote SXT excision upregulate mosAT expression. Thus, when the element is extrachromosomal and vulnerable to loss, SXT activates a TA module to minimize the formation of SXT-free cells

Bacteriophage Crosstalk: Coordination of Prophage Induction by Trans-Acting Antirepressors

Many species of bacteria harbor multiple prophages in their genomes. Prophages often carry genes that confer a selective advantage to the bacterium, typically during host colonization. Prophages can convert to infectious viruses through a process known as induction, which is relevant to the spread of bacterial virulence genes. The paradigm of prophage induction, as set by the phage Lambda model, sees the process initiated by the RecA-stimulated self-proteolysis of the phage repressor. Here we show that a large family of lambdoid prophages found in Salmonella genomes employs an alternative induction strategy. The repressors of these phages are not cleaved upon induction; rather, they are inactivated by the binding of small antirepressor proteins. Formation of the complex causes the repressor to dissociate from DNA. The antirepressor genes lie outside the immunity region and are under direct control of the LexA repressor, thus plugging prophage induction directly into the SOS response. GfoA and GfhA, the antirepressors of Salmonella prophages Gifsy-1 and Gifsy-3, each target both of these phages' repressors, GfoR and GfhR, even though the latter proteins recognize different operator sites and the two phages are heteroimmune. In contrast, the Gifsy-2 phage repressor, GtgR, is insensitive to GfoA and GfhA, but is inactivated by an antirepressor from the unrelated Fels-1 prophage (FsoA). This response is all the more surprising as FsoA is under the control of the Fels-1 repressor, not LexA, and plays no apparent role in Fels-1 induction, which occurs via a Lambda CI-like repressor cleavage mechanism. The ability of antirepressors to recognize non-cognate repressors allows coordination of induction of multiple prophages in polylysogenic strains. Identification of non-cleavable gfoR/gtgR homologues in a large variety of bacterial genomes (including most Escherichia coli genomes in the DNA database) suggests that antirepression-mediated induction is far more common than previously recognized