Acute Arterial Thrombosis after Covered Stent Exclusion of Bleeding Mycotic Pseudoaneurysm: Treatment Using Catheter-Directed Thrombolysis

Conventional absolute contraindications to catheter-directed thrombolysis include active or recent hemorrhage and the presence of local vascular infection, both of which increase the risk of procedure-related complications such as bleeding and systemic sepsis. For this reason, lytic therapy of arterial thromboembolism under these circumstances is generally precluded. Herein, we describe a unique case of safe catheter-directed lysis of an acutely thrombosed iliac artery following covered stent placement for treatment of an actively bleeding infected pseudoaneurysm. Our management approach is discussed

Strategic Implications of COVID-19: Considerations for Georgia’s Rural Health Providers

Whether rural hospitals and providers have seen a surge in COVID-19 cases or a reduction in patients seeking care since the pandemic began, their financial condition has been negatively impacted. Many providers have now received some emergency funding through the Coronavirus Aid, Relief, and Economic Security Act and the Payroll Protection Program but these are likely only short-term fixes. For many, the crisis has exacerbated already existing problems. Notable among these problems are volume declines, supply chain disruptions, and workforce concerns. While these problems require immediate action, two longer-term systemic changes to rural healthcare delivery are needed to address them. Proactive adoption of telehealth is essential to stake a value-added position in delivery of healthcare. Creating a regional ecosystem that both supports, and receives support from, local businesses and potential workforce members is vital to building and maintaining a thriving organization. Rural healthcare providers must consider these strategies to ensure that they are able to continue delivering their mission of improving the health of the populations they serve

The Varga Site: A Multicomponent, Stratified Campsite in the Canyonlands of Edwards County, Texas

Data recovery excavations at the Varga Site were conducted in two phases during 2002 by archeologists from the Cultural Resources Department of TRC Environmental Corporation’s (TRC’s) Austin office under contract to Texas Department of Transportation (TxDOT) Scientific Service Contract No. 572XXSA004. This mitigation program was necessitated by the proposed reconstruction of the crossing of a Ranch to Market Road over Hackberry Creek, immediately south of the site in northeastern Edwards County. These archeological investigations were conducted as part of the responsibilities of TxDOT under existing federal and state legislation for the protection of cultural resources. Geoarcheological trenching and hand-excavations within the existing 31 m wide road right-of-way of 7- m-wide paved Ranch to Market Road focused on the alluvial fines in the first terrace overlooking Hackberry Creek immediately adjacent to a spring. The southern edge of the terrace contains relatively fine-grained sediments ranging from 15 to 150 centimeter (cm) thick that overlie coarse stream gravels that extend to an unknown depth. The modern ground surface had been impacted by road construction and maintenance activities, as well as by light erosion. Block Excavations were conducted on both sides of the pavement and resulted in the hand-excavations of a total of 207.75 square meters (m2), including 83 m2 (66.2 m3) in Block A on the western side and a 124.75 m2 (38.26 m3) area in Block B on the eastern side. Archeological deposits in the investigated part of the site extend to the southern lip of the first terrace and extend about 50 m to the north. The excavations yielded evidence of a multiple component campsite with three distinct and a fourth less distinct prehistoric components. In Block A, the 100 to 150 cm thick fine-grained sediments yielded four intact cultural components. Block B only targeted the youngest, Toyah component. The fine-grained alluvial sediments that comprise the first terrace contain discrete occupations radiocarbon dated to the Late Prehistoric period Toyah phase (ca. 290 to 660 B.P.), the Late Archaic period (ca. 1,700 to 2,300 B.P.), and the Early Archaic period (ca. 5,200 to 6,300 B.P.). A Middle Archaic period (ca. 3,900 to 4,800 B.P.) component was also recognized, but was not as clearly defined as were the other three components. Krotovina disturbance was relatively extensive in parts of the investigated site area. Nevertheless, the archeological deposits exhibited a high degree of contextual integrity. The Toyah phase component contains a rich assemblage of cultural material (ca. 65,000 pieces), including lithic debitage (ca. 26,000), quantities of highly fragmented bones (ca. 18,700), small burned rocks (ca. 16,000), formal and informal stone tools (ca. 1,850), scattered ceramic sherds (ca. 100), and 11 burned rock features. This component was radiocarbon dated by 14 accepted dates to between 290 and 660 B.P. Preservation was generally good, but mixing and probable overprinting contributed to poor horizontal patterning and an inability to identify discrete activity areas. The Late Archaic period component consists primarily of a large, nearly 6 m diameter lens of burned rock that is interpreted as an incipient burned rock midden with an indistinct central pit oven. This feature was associated with a buried A horizon and exhibited a high degree of stratigraphic integrity. However, beyond the ill-defined boundaries of this burned rock feature, limited lithic debitage assemblage (ca. 1,800), a few mussel shell fragments, five isolated burned rock features, scattered burned rocks, and occasional chipped stone tools (ca. 30) totaling less than 6,000 pieces. Identified dart point styles associated with this midden include Frio, Marcos, Ensor, Castroville, and Edgewood. This component was radiocarbon dated by 11 accepted dates to a 600-year period between 1,700 and 2,310 B.P. The Middle Archaic component was not well-defined, but definitely present and dispersed below the Late Archaic component and above the Early Archaic component. These materials were vertically distributed over a 20 to 40 cm thick zone that lacked completely sterile levels or visible breaks in the stratigraphy between the other cultural events. Lithic debitage (ca. 4,400) dominates the recovered assemblage (ca. 6,000), with limited burned rocks (ca. 3,000), a few formal chipped stone tools (ca. 25), and moderate frequency of vertebrate remains (100 g) also present. Two poorly organized burned rock features were also identified and documented. Five Early Triangular projectile points and one Carrizo point fragment occurred within this component. Two wood charcoal assays and one radiocarbon date on a deer bone directly date this Middle Archaic component to ca. 900-radiocarbon year period between 3,910 and 4,820 B.P. These three absolute dates are stratigraphically in order compared to the radiocarbon dates from the cultural components above and below. The Early Archaic component was defined by quantities of dense cultural debris (ca. 135,000) within a roughly 30 cm thick zone directly on top and mixed into coarse river gravels and below the Middle Archaic component. The cultural material varied in depth from a shallow 50 cm below datum (bd) at the north end to a much deeper 120 cmbd in the southern end of Block A. The recovery of a robust assemblage of dart points (170 specimens) that consisted of Group 2—Early Corner-Notched, Bandy, Martindale, Gower, and Merrell dart points indicates that this zone represents many occupations that occurred over a relatively broad time frame. The dart points were associated with a diverse tool assemblage (ca. 1,300). Organic preservation was poor in this lower stratum, but occasional fragments of animal bone, plant seeds, and wood charcoal were recovered. Fifteen organic samples of diverse materials yielded radiocarbon dates that document a minimum use period of 1,080-radiocarbon years from 5,200 B.P. to 6,280 B.P. Greater insight and understanding of each of these four components represented was made possible through the employment of numerous technical analyses, including the radiocarbon dating of 66 samples, six optically stimulated luminescence dates, use-wear analysis and organic residue identifications on 156 stone specimens, petrographic analyses on 18 pottery and one local sediment samples, pollen and phytolith analyses on 25 paired samples, instrumental neutron activation analysis on 261 chert samples and 18 pottery sherds, fatty acid composition on eight pottery sherds and 94 burned rocks, stable carbon and nitrogen analyses on 112 samples, macrobotanical analyses on 44 float and 75 individual charcoal samples, and granulometric and compositional studies on 10 sediment samples. The combined results have contributed significantly to a greater understanding of the Varga Site as a whole and documented specific information concerning the behaviors of the people who occupied the site. These and other technical analyses are urged for other excavated sites in the future to continue to broaden our understanding of the human behaviors at specific sites and throughout the broader region. This will add to a growing database that will foster a better understanding of prehistoric lifeways across Texas

Neutrino, Neutron, and Cosmic Ray Production in the External Shock Model of Gamma Ray Bursts

The hypothesis that ultra-high energy (>~ 10^19 eV) cosmic rays (UHECRs) are accelerated by gamma-ray burst (GRB) blast waves is assumed to be correct. Implications of this assumption are then derived for the external shock model of gamma-ray bursts. The evolving synchrotron radiation spectrum in GRB blast waves provides target photons for the photomeson production of neutrinos and neutrons. Decay characteristics and radiative efficiencies of the neutral particles that escape from the blast wave are calculated. The diffuse high-energy GRB neutrino background and the distribution of high-energy GRB neutrino events are calculated for specific parameter sets, and a scaling relation for the photomeson production efficiency in surroundings with different densities is derived. GRBs provide an intense flux of high-energy neutrons, with neutron-production efficiencies exceeding ~ 1% of the total energy release. The radiative characteristics of the neutron beta-decay electrons from the GRB "neutron bomb" are solved in a special case. Galaxies with GRB activity should be surrounded by radiation halos of ~ 100 kpc extent from the outflowing neutrons, consisting of a nonthermal optical/X-ray synchrotron component and a high-energy gamma-ray component from Compton-scattered microwave background radiation. The luminosity of sources of GRBs and relativistic outflows in L* galaxies such as the Milky Way is at the level of ~10^40+-1 ergs/s. This is sufficient to account for UHECR generation by GRBs. We briefly speculate on the possibility that hadronic cosmic rays originate from the subset of supernovae that collapse to form relativistic outflows and GRBs. (abridged)Comment: 53 pages, 8 figures, ApJ, in press, 574, July 20, 2002. Substantial revision, previous Appendix expanded to ApJ, 556, 479; cosmic ray origin speculations to Heidelberg (astro-ph/001054) and Hamburg ICRC (astro-ph/0202254) proceeding

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

The Clinical Impact of Continuing to Prescribe Antiretroviral Therapy in Patients with Advanced AIDS Who Manifest No Virologic or Immunologic Benefit

Introduction: Despite the efficacy and tolerability of modern antiretroviral therapy (ART), many patients with advanced AIDS prescribed these regimens do not achieve viral suppression or immune reconstitution as a result of poor adherence, drug resistance, or both. The clinical outcomes of continued ART prescription for such patients have not been well characterized. Methods: We examined the causes and predictors of all-cause mortality, AIDS-defining conditions, and serious non-AIDS-defining events among a cohort of participants in a clinical trial of pre-emptive therapy for CMV disease. We focused on participants who, despite ART had failed to achieve virologic suppression and substantive immune reconstitution. Results: 233 ART-receiving participants entered with a median baseline CD4+ T cell count of 30/mm3 and plasma HIV RNA of 5 log10 copies/mL. During a median 96 weeks of follow-up, 24.0% died (a mortality rate of 10.7/100 patient-years); 27.5% reported a new AIDS-defining condition, and 22.3% a new serious non-AIDS event. Of the deaths, 42.8% were due to an AIDS-defining condition, 44.6% were due to a non-AIDS-defining condition, and 12.5% were of unknown etiology. Decreased risk of mortality was associated with baseline CD4+ T cell count ≥25/mm3 and lower baseline HIV RNA. Conclusions: Among patients with advanced AIDS prescribed modern ART who achieve neither virologic suppression nor immune reconstitution, crude mortality percentages appear to be lower than reported in cohorts of patients studied a decade earlier. Also, in contrast to the era before modern ART became available, nearly half of the deaths in our modern-era study were caused by serious non-AIDS-defining events. Even among the most advanced AIDS patients who were not obtaining apparent immunologic and virologic benefit from ART, continued prescription of these medications appears to alter the natural history of AIDS—improving survival and shifting the causes of death from AIDS- to non-AIDS-defining conditions

Coronal Hole Detection and Open Magnetic Flux

Many scientists use coronal hole (CH) detections to infer open magnetic flux. Detection techniques differ in the areas that they assign as open, and may obtain different values for the open magnetic flux. We characterize the uncertainties of these methods, by applying six different detection methods to deduce the area and open flux of a near-disk center CH observed on 2010 September 19, and applying a single method to five different EUV filtergrams for this CH. Open flux was calculated using five different magnetic maps. The standard deviation (interpreted as the uncertainty) in the open flux estimate for this CH ≈ 26%. However, including the variability of different magnetic data sources, this uncertainty almost doubles to 45%. We use two of the methods to characterize the area and open flux for all CHs in this time period. We find that the open flux is greatly underestimated compared to values inferred from in situ measurements (by 2.2–4 times). We also test our detection techniques on simulated emission images from a thermodynamic MHD model of the solar corona. We find that the methods overestimate the area and open flux in the simulated CH, but the average error in the flux is only about 7%. The full-Sun detections on the simulated corona underestimate the model open flux, but by factors well below what is needed to account for the missing flux in the observations. Under-detection of open flux in coronal holes likely contributes to the recognized deficit in solar open flux, but is unlikely to resolve it

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

A Highly Active Esterase from \u3cem\u3eLactobacillus helveticus\u3c/em\u3e Hydrolyzes Chlorogenic Acid in Sunflower Meal to Prevent Chlorogenic Acid Induced Greening in Sunflower Protein Isolates

Chlorogenic acid (CGA) is an ester between caffeic and quinic acid. It is found in many foods and reacts with free amino groups in proteins at alkaline pH, leading to the formation of an undesirable green pigment in sunflower seed-derived ingredients. This paper presents the biochemical characterization and application of a highly active chlorogenic acid esterase from Lactobacillus helveticus. The enzyme is one of the most active CGA esterases known to date with a Km of 0.090 mM and a kcat of 82.1 s−1. The CGA esterase is easily expressed recombinantly in E. coli in large yields and is stable over a wide range of pH and temperatures. We characterized CGA esterase’s kinetic properties in sunflower meal and demonstrated that the enzyme completely hydrolyzes CGA in the meal. Finally, we showed that CGA esterase treatment of sunflower seed meal enables the production of pale brown sunflower protein isolates using alkaline extraction. This work will allow for more widespread use of sunflower-derived products in applications where neutrally-colored food products are desired