ARDS in solid organ transplant recipients hospitalized for COVID-19 based on the 2023 new definition.

BACKGROUND: Solid organ transplant recipients (SOTRs) are more likely to suffer complications after being infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). OBJECTIVES: We aimed to describe the clinical features of SOTRs infected with SARS-CoV-2 and to assess independent risk factors associated with the development of acute respiratory distress syndrome (ARDS) following COVID-19 infection in SOTRs based on the new ARDS definition. METHODS: 358 SOTRs infected with SARS-CoV-2 were recruited and divided into two groups, patients with ARDS (n = 81) and patients without ARDS (n = 277). Demographic data, initial laboratory findings, therapeutic measures, and outcome indicators were compared between the two groups. The association between the onset of ARDS and related factors was analyzed using a logistic regression model. A nomogram was created to estimate the probability of developing ARDS. RESULTS: Approximately 22.6 % (81/358) of hospitalized SOTRs infected with SARS-CoV-2 developed ARDS. In comparison to patients without ARDS, those with ARDS presented with more underlying conditions, decreased lymphocyte counts and serum albumin levels, but increased levels of leukocytes, serum creatinine, nitrogen urea, uric acid, and inflammatory markers. Cerebrovascular disease, leukocyte counts, albumin levels, and IL-6 levels were independent risk factors for the development of ARDS in this population. Furthermore, a nomogram prediction model was created utilizing the aforementioned factors to facilitate early prediction of ARDS, exhibiting an AUC (area under curve) of 0.81. CONCLUSIONS: Cerebrovascular disease, leukocyte counts, albumin levels, and IL-6 levels were independent risk factors for the development of ARDS following COVID-19 infection in SOTRs.

Nanoplastic impacts on the foliar uptake, metabolism and phytotoxicity of phthalate esters in corn (Zea mays L.) plants.

Nanoplastic pollution in terrestrial plants is of increasing concern for its negative effects on living organisms. However, the impacts of nanoplastics on chemical processes and plant physiology of phthalate esters (PAEs) remain unclear. The present work offers insight into the foliar uptake, metabolism and phytotoxicity of two typical PAEs, namely, di-n-butyl phthalate (DBP) and di-(2-ethylhexyl) phthalate (DEHP), in corn (Zea mays L.) seedlings and the effects of amino-functionalized polystyrene nanoplastics (PSNPs-NH2). The presence of PSNPs-NH2 increased DBP and DEHP accumulation in the leaves by 1.36 and 1.32 times, respectively. PSNPs-NH2 also promoted the leaf-to-root translocation of DBP and DEHP, with the translocation factor increasing by approximately 1.05- and 1.16-fold, respectively. Furthermore, the addition of PSNPs-NH2 significantly enhanced the transformation of PAEs to their primary metabolites, mono-butyl phthalate and mono(2-ethylhexyl) phthalate in corn leaves and roots. The co-presence of PSNPs-NH2 and PAEs showed stronger impairment of photosystem II efficiency via the downregulation of transporter D1 protein, thus exhibiting a greater inhibitory effect on plant growth. Our findings reveal that nanoplastics promote the foliar uptake and transformation of PAE chemicals in crops and exacerbate their toxicity to crop plants, thereby threatening agricultural safety and human health.

Characterizing Physician Practice in Nursing Homes Using Claims-Based Measures: Correlation With Nursing Home Administrators' Perceptions.

Heterogeneity in physician practice within nursing homes (NHs) may explain variations in quality. However, data on physician practice organization in NHs are hard to obtain. We characterized NH physician practice using two claims-based measures: (a) concentration of NH care among physicians (measured by Herfindahl-Hirschman index of visits); and (b) physician NH practice specialization (measured by the proportion of a physician's visits to NHs). We examined the relationship between the measures and NH administrator perceptions of physician practice reported in the Shaping Long-Term Care in America (SLTCA) Survey. All 2011 Part B claims from 13,718 physicians who treated Medicare fee-for-service patients in 2,095 NHs in the SLTCA survey were analyzed. The median Herfindahl-Hirschman index was 0.44 (interquartile range [IQR] 0.28-0.70), and the median specialization was 38.1% (IQR 19.9% to 60.9%). NHs with higher physician specialization reported more frequent physician participation in care coordination activities. Claims-based measures could inform the study of NH physician practice.

Hospitalist Vs. Non-Hospitalist Care Outcomes and Costs for Medicare Beneficiaries Discharged to Skilled Nursing Facilities in 2012-2014.

BACKGROUND: Hospitals are increasingly at risk for post-acute care outcomes and spending, such as those in skilled nursing facilities (SNFs). While hospitalists are thought to improve patient outcomes of acute care, whether these effects extend to the post-acute setting in SNFs is unknown. OBJECTIVE: To compare longer term outcomes of patients discharged to SNFs who were treated by hospitalists vs. non-hospitalists during their hospitalization. DESIGN: This was a retrospective cohort study. PARTICIPANTS: Participants are Medicare fee-for-service beneficiaries over 66 years of age who were hospitalized and discharged to a SNF in 2012-2014 (N = 2,839,779). MAIN MEASURES: We estimated the effect of being treated by a hospitalist on 30-day rehospitalization and mortality, 60-day episode Medicare payments (Parts A and B), and successful discharge to community. Patients discharged to the community within 100 days of SNF admission who remained alive and not readmitted to a hospital or SNF for at least 30 days were considered successfully discharged. All outcomes were adjusted for demographics and clinical characteristics. To account for heterogeneity across facilities, we included hospital fixed effects. KEY RESULTS: The 30-day rehospitalization rate was 17.59% for hospitalists' vs. 17.31% for non-hospitalists' patients (adjusted difference, 0.28%; 95% CI, 0.13 to 0.44). Sixty-day payments were $26,301 for hospitalists' vs. $25,996 for non-hospitalists' patients (adjusted difference, $305; 95% CI, $243 to $367). There was a non-significant trend toward lower successful discharge to the community rate (adjusted difference, - 0.26%; 95% CI, - 0.48 to - 0.04) and lower mortality for patients of hospitalists (adjusted difference, - 0.12%; 95% CI, - 0.22 to - 0.02). CONCLUSIONS: Among hospitalized Medicare beneficiaries who were discharged to SNFs, readmissions and Medicare costs were slightly higher for stays under the care of hospitalists compared with those of non-hospitalist generalist physicians, but there was a non-significant trend toward lower mortality.

Potentially Preventable Intensive Care Unit Admissions in the United States, 2006-2015.

Rationale: Increasing intensive care unit (ICU) beds and the critical care workforce are often advocated to address an aging and increasingly medically complex population. However, reducing potentially preventable ICU stays may be an alternative to ensure adequate capacity.Objectives: To determine the proportions of ICU admissions meeting two definitions of being potentially preventable using nationally representative U.S. claims databases.Methods: We analyzed claims from 2006 to 2015 from all Medicare Fee-for-Service (FFS) beneficiaries and from a large national payer offering a private insurance (PI) plan and a Medicare Advantage (MA) plan. Potentially preventable hospitalizations were identified using existing definitions for ambulatory care sensitive conditions (ACSCs) and life-limiting malignancies (LLMs).Results: We analyzed 420,369,434 person-years of insurance coverage, during which there were 99,793,416 acute inpatient hospitalizations, of which 16,646,977 (16.7%) were associated with an ICU admission. Of these, the proportions with an ACSC were 12.9%, 12.7%, and 15.8%, and with an LLM were 5.2%, 5.4%, and 6.4%, among those with PI, MA, and FFS, respectively. Over 10 years, the absolute percentages of ACSC-associated ICU stays declined (PI = -1.1%, MA -6.4%, FFS -6.4%; all P < 0.001 for all trends). Smaller changes were noted among LLM-associated ICU stays, declining in the MA cohort (-0.8%) and increasing in the FFS (+0.3%) and PI (+0.2%) populations (P < 0.001 for all trends).Conclusions: An appreciable proportion of U.S. ICU admissions may be preventable with community-based interventions. Investment in the outpatient infrastructure required to prevent these ICU admissions should be considered as a complementary, if not alternative, strategy to expanding ICU capacity to meet future demand.

Medicare's bundled payment model did not change skilled nursing facility discharge patterns.

OBJECTIVES: To evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration. STUDY DESIGN: Retrospective observational study using difference-in-differences analysis. METHODS: We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals. RESULTS: Our analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups. CONCLUSIONS: Hospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.

Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults.

Importance: High use of subspecialty care is an important source of health care spending. Medical subspecialty care in particular may duplicate the scope of practice of the primary attending physicians for patients hospitalized for medical conditions. Under value-based payments, which aim to control overall spending during an episode of hospitalization (including Part B physician fees), subspecialty consultations may be a target for hospitals working to reduce costs. Objectives: To measure the use of subspecialty consultation for Medicare beneficiaries hospitalized for nonsurgical conditions; to compare payments for consultative and nonconsultative care, adjusted for case mix and demographics; and to measure variation in payments across hospital referral regions (HRRs). Design, Setting, and Participants: This retrospective cross-sectional study included a 15% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A and B and identified all discharges after acute care hospital stays for nonsurgical conditions from January 1 through December 31, 2014. A total of 735 627 discharges were included. The analyses were conducted from December 1, 2017, through February 12, 2019. Total Part B payments were extrapolated to the population of Medicare fee-for-service beneficiaries. Main Outcomes and Measures: Probability of any consultation during a hospitalization was estimated using logistic regression. The number of consultations per stay and the number of consultative visits per hospital day were estimated using Poisson regression. Part B payments for consultative and nonconsultative care were estimated using generalized linear regression with gamma-log link. All models were adjusted for patient demographics and case mix. Payment models also included HRR fixed effects. Results: A total of 735 627 discharges from 4534 hospitals in 2014 were included in the analysis (41.2% men and 58.8% women; mean [SD] age, 79.6 [8.9] years; 84.7% white, 10.1% black, and 5.2% other race). After adjusting for patient case mix and demographics, a 6-fold variation between the top and bottom quintiles of hospitals (relative difference, $401 [95% CI, $368-$434]) and HRRs (relative difference, $363 [95% CI, $337-$389]) was found in payments per stay for consultative care. Part B payments for consultative care by medical subspecialists accounted for 41.3% of payments for physician visits during hospitalization and totaled $1.3 billion in 2014. Conclusions and Relevance: The substantial variation in the use of subspecialty consultative care suggests potential opportunities for cost savings.

Assessing First Visits By Physicians To Medicare Patients Discharged To Skilled Nursing Facilities.

Although approximately one in five Medicare beneficiaries are discharged from hospital acute care to postacute care at skilled nursing facilities (SNFs), little is known about access to timely medical care for these patients after they are admitted to a SNF. Our analysis of 2,392,753 such discharges from hospitals under fee-for-service Medicare in the period January 2012-October 2014 indicated that first visits by a physician or advanced practitioner (a nurse practitioner or physician assistant) for initial medical assessment occurred within four days of SNF admission in 71.5 percent of the stays. However, there was considerable variation in days to first visit at the regional, facility, and patient levels. We estimated that in 10.4 percent of stays there was no physician or advanced practitioner visit. Understanding the underlying reasons for, and consequences of, variability in timing and receipt of initial medical assessment after admission to a SNF for postacute care may prove important for improving patient outcomes and particularly relevant to current efforts to promote value-based purchasing in postacute care.

Postacute care outcomes and medicare payments for patients treated by physicians and advanced practitioners who specialize in nursing home practice.

OBJECTIVE: To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs). DATA SOURCES: Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians. STUDY DESIGN: Generalist physicians and advanced practitioners with ≥ 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects. PRINCIPAL FINDINGS: Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429). CONCLUSIONS: Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs.

Do Hospitals Participating in Accountable Care Organizations Discharge Patients to Higher Quality Nursing Homes?

We examined whether hospitals participating in Medicare's Shared Saving Program increased the use of highly rated skilled nursing facilities (SNFs) or decreased the use of low-rated SNFs hospital-wide after initiation of their accountable care organization (ACO) contracts compared with non-ACO hospitals. Using a difference-in-differences design, we estimated the change in the probability of discharge to 5-star and 1-star SNFs among all beneficiaries discharged from ACO-participating hospitals after the hospital initiated ACO participation. After joining an ACO, the percentage of hospital discharges going to a high-quality SNF increased by 3.4 percentage points on a base of 15.4% (95% confidence interval [CI] 1.3-5.5, P = .002) compared with non-ACO-participating hospitals. The probability of discharge from an ACO-participating hospital to low-quality SNFs did not change significantly compared with non-ACO-participating hospitals. Our findings indicate that ACO-participating hospitals were more likely to discharge patients to highly rated SNFs after they began their ACO contract but did not change the likelihood of discharge to lower rated SNFs in comparison with non-ACO hospitals.

In Situ Complex with by-product HCl and Release Chloride Ions to Dissolve Aramid.

Because of the strong hydrogen-bond interaction among macromolecular chains, the addition of chloride salts is generally needed to offer Cl- ions for the dissolution of aromatic polyamides. In this paper, poly-(benzimidazole-terephthalamide) which complexed with by-product HCl during polymerization (PABI-HCl) was prepared and imidazole compound as cosolvent was added into dimethylacetamide (DMAc) to dissolve PABI-HCl. Due to stronger affinity to protons, imidazole compound could in-situ complex with HCl of PABI-HCl and form imidazolium hydrochloride. Then imidazolium hydrochloride would ionize and produce much free Cl- ions which acted as stronger hydrogen-bond acceptor to disrupt interaction among macromolecular chains. As a result, solubility of PABI-HCl in DMAc was improved significantly in existence of small amount of imidazole compound. Moreover, DMAc-imidazole mixture was utlized for synthesis of different kinds of aramids and no precipitation was observed with progress of the reaction. So the mixture was suitable to be utlized as solvent for polymerization of aramid.

Control of Head/Tail Isomeric Structure in Polyimide and Isomerism-Derived Difference in Molecular Packing and Properties.

Two sequence isomeric poly(amic acid)s (PAAs) are successfully synthesized from 3,3',4,4'-biphenyltetracarboxylic dianhydride and unsymmetrical 5(6)-amino-2-(4-aminobenzene) benzimidazole (PABZ). The syntheses are based on the site-selective reactivity of head/tail amino groups of PABZ and solubility differences of PABZ in good solvent (dimethyl sulfoxide, DMSO) and poor solvent (N-methyl-2-pyrrolidone, NMP). The proton nuclear magnetic resonance (1 H-NMR) results reveal that the content of head tail-head tail (HTHT) bonding units in PAA-DMSO (PAA synthesized in DMSO) is 37%, while this content increases to 54% in PAA-NMP (PAA synthesized in NMP). The wide-angle X-ray diffraction (WAXD) results indicate polyimide (PI)-NMP film with high HTHT content exhibits a semicrystalline structure, while PI-DMSO film is amorphous. Moreover, PI-NMP also shows higher in-plane orientation than PI-DMSO. The ordered molecular packing and higher in-plane orientation of PI-NMP lead to an increase in mechanical properties and a decrease in in-plane thermal expansion coefficient.