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

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

Preventing Chlorogenic Acid Quinone-Induced Greening in Sunflower Cookies by Chlorogenic Acid Esterase and Thiol-based Dough Conditioners

Sunflower seeds contain a high concentration of chlorogenic acid (CGA), which reacts with amino acids to form green pigments under alkaline conditions during food processing. Here, we present two approaches to prevent green pigment formation in sunflower cookies by (A) Addition of free thiols from cysteine and glutathione to sunflower cookie dough and (B) hydrolyzing CGA into caffeic acid and quinic acid with a CGA esterase from Lactobacillus helveticus. Greening occurred more slowly with cysteine; however, neither cysteine nor glutathione prevented greening in the cookies during storage. Chlorogenic acid esterase hydrolyzed CGA in both sunflower butter and flour, resulting in the complete elimination of greening in the sunflower cookies. CGA esterase treatment was efficient as the enzyme could be applied in low amounts (\u3c100 ppm) directly to the dough without needing to pretreat either sunflower butter or flour. Overall, our data indicate that CGA esterase treatment was an effective method of eliminating unwanted greening in sunflower cookies made with baking soda. Long term, these results may represent a method of increasing the use of sunflower butter and flour in high pH baking applications by enabling their use in neutrally colored baked products such as cookies and muffins

Combination therapy with rituximab, low-dose cyclophosphamide, and prednisone for idiopathic membranous nephropathy: a case series

BACKGROUND: Membranous nephropathy is a common cause of the nephrotic syndrome. Treatment with standard regimens fails to induce complete remission in most patients. We evaluated the efficacy of combination therapy with rituximab, low-dose, oral cyclophosphamide, and an accelerated prednisone taper (RCP) for the treatment of idiopathic membranous nephropathy. METHODS: We analyzed 15 consecutive patients with idiopathic membranous nephropathy treated with RCP at Massachusetts General Hospital. Seven patients (47%) received RCP as initial therapy, and the other eight patients (53%) received RCP for relapsing or refractory disease. All patients had at least 1 year of follow-up. The co-primary outcomes were attainment of partial and complete remission. Partial remission was defined as a urinary protein to creatinine ratio (UPCR) < 3 g/g and a 50% reduction from baseline. Complete remission was defined as a UPCR < 0.3 g/g. Secondary outcomes were serious adverse events and the change in proteinuria, serum creatinine, serum albumin, cholesterol, triglycerides, and immunoglobulin G levels after 1 year of treatment. RESULTS: Over a median follow-up time of 37 (IQR, 34-44) months, 100% of patients achieved partial remission and 93% of patients achieved complete remission at a median time of 2 and 13 months, respectively. After 1 year of treatment, median (IQR) UPCR declined from 8.2 (6.6-11.1) to 0.3 (0.2-0.7) g/g (P < 0.001). Three serious adverse events occurred over 51 patient years. No patients died or progressed to ESKD. CONCLUSIONS: Treatment of idiopathic membranous nephropathy with RCP resulted in high rates of complete remission. Larger studies evaluating this regimen are warranted

The Structure of a \u3cem\u3eLactobacillus helveticus\u3c/em\u3e Chlorogenic Acid Esterase and the Dynamics of Its Insertion Domain Provide Insights into Substrate Binding

Chlorogenic acid esterases (ChlEs) are a useful class of enzymes that hydrolyze chlorogenic acid (CGA) into caffeic and quinic acid. ChlEs can break down CGA in foods to improve their sensory properties and release caffeic acid in the digestive system to improve the absorption of bioactive compounds. This work presents the structure, molecular dynamics, and biochemical characterization of a ChlE from Lactobacillus helveticus (Lh). Molecular dynamics simulations suggest that substrate access to the active site of LhChlE is modulated by two hairpin loops above the active site. Docking simulations and mutational analysis suggest that two residues within the loops, Gln145 and Lys164, are important for CGA binding. Lys164 provides a slight substrate preference for CGA, whereas Gln145 is required for efficient turnover. This work is the first to examine the dynamics of a bacterial ChlE and provides insights on the substrate binding preference and turnover in this type of enzyme

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

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

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

Quantitative morphometric analysis of hepatocellular carcinoma: development of a programmed algorithm and preliminary application

PURPOSEThe quantitative relationship between tumor morphology and malignant potential has not been explored in liver tumors. We designed a computer algorithm to analyze shape features of hepatocellular carcinoma (HCC) and tested feasibility of morphologic analysis. MATERIALS AND METHODSCross-sectional images from 118 patients diagnosed with HCC between 2007 and 2010 were extracted at the widest index tumor diameter. The tumor margins were outlined, and point coordinates were input into a MATLAB (MathWorks Inc., Natick, Massachusetts, USA) algorithm. Twelve shape descriptors were calculated per tumor: the compactness, the mean radial distance (MRD), the RD standard deviation (RDSD), the RD area ratio (RDAR), the zero crossings, entropy, the mean Feret diameter (MFD), the Feret ratio, the convex hull area (CHA) and perimeter (CHP) ratios, the elliptic compactness (EC), and the elliptic irregularity (EI). The parameters were correlated with the levels of alpha-fetoprotein (AFP) as an indicator of tumor aggressiveness. RESULTSThe quantitative morphometric analysis was technically successful in all cases. The mean parameters were as follows: compactness 0.88±0.086, MRD 0.83±0.056, RDSD 0.087±0.037, RDAR 0.045±0.023, zero crossings 6±2.2, entropy 1.43±0.16, MFD 4.40±3.14 cm, Feret ratio 0.78±0.089, CHA 0.98±0.027, CHP 0.98±0.030, EC 0.95±0.043, and EI 0.95±0.023. MFD and RDAR provided the widest value range for the best shape discrimination. The larger tumors were less compact, more concave, and less ellipsoid than the smaller tumors (P < 0.0001). AFP-producing tumors displayed greater morphologic irregularity based on several parameters, including compactness, MRD, RDSD, RDAR, entropy, and EI (P < 0.05 for all). CONCLUSIONComputerized HCC image analysis using shape descriptors is technically feasible. Aggressively growing tumors have wider diameters and more irregular margins. Future studies will determine further clinical applications for this morphologic analysis