Switchable tribology of ferroelectrics.

Switchable tribological properties of ferroelectrics offer an alternative route to visualize and control ferroelectric domains. Here, we observe the switchable friction and wear behavior of ferroelectrics using a nanoscale scanning probe-down domains have lower friction coefficients and show slower wear rates than up domains and can be used as smart masks. This asymmetry is enabled by flexoelectrically coupled polarization in the up and down domains under a sufficiently high contact force. Moreover, we determine that this polarization-sensitive tribological asymmetry is widely applicable across various ferroelectrics with different chemical compositions and crystalline symmetry. Finally, using this switchable tribology and multi-pass patterning with a domain-based dynamic smart mask, we demonstrate three-dimensional nanostructuring exploiting the asymmetric wear rates of up and down domains, which can, furthermore, be scaled up to technologically relevant (mm-cm) size. These findings demonstrate that ferroelectrics are electrically tunable tribological materials at the nanoscale for versatile applications.

Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model.

Importance: The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. Objective: To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk. Design, Setting, and Participants: A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. Exposure: Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. Main Outcomes and Measures: Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. Results: Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions: In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Enhanced Hot Electron Flow and Catalytic Synergy by Engineering Core-Shell Structures on Au-Pd Nanocatalysts.

The synergistic catalytic performances of bimetallic catalysts are often attributed to the reaction mechanism associated with the alloying process of the catalytic metals. Chemically induced hot electron flux is strongly correlated with catalytic activity, and the interference between two metals at the atomic level can have a huge impact on the hot electron generation on the bimetallic catalysts. In this study, we investigate the correlation between catalytic synergy and hot electron chemistry driven by the electron coupling effect using a model system of Au-Pd bimetallic nanoparticles. We show that the bimetallic nanocatalysts exhibit enhanced catalytic activity under the hydrogen oxidation reaction compared with that of monometallic Pd nanocatalysts. Analysis of the hot electron flux generated in each system revealed the formation of Au/PdOx interfaces, resulting in high reactivity on the bimetallic catalyst. In further experiments with engineering the Au@Pd core-shell structures, we reveal that the hot electron flux, when the topmost surface Pd atoms were less affected by inner Au, due to the concrete shell, was smaller than the alloyed one. The alloyed bimetallic catalyst forming the metal-oxide interfaces has a more direct effect on the hot electron chemistry, as well as on the catalytic reactivity. The great significance of this study is in the confirmation that the change in the hot electron formation rate with the metal-oxide interfaces can be observed by shell engineering of nanocatalysts.

Determination of the Spatial Distribution of Air Pollutants in Bucheon, Republic of Korea, in Winter Using a GIS-Based Mobile Laboratory.

Driven by industrialization and urbanization, urban air pollution can increase respiratory, heart, and cerebrovascular diseases, and thus mortality rates; as such, it is necessary to improve air quality through the consideration of individual pollutants and emission sources. In Republic of Korea, national and local governments have installed urban and roadside air quality monitoring systems. However, stations are lacking outside metropolitan regions, and roadside stations are sparsely distributed, limiting comparisons of pollutant concentrations with vehicle traffic and floating population levels. Local governments have begun using mobile laboratories (MLs) to supplement the fixed measurement network and investigate road pollution source characteristics based on their spatiotemporal distribution; however, the collected data cannot be used effectively if they are not visualized. Here, we propose a method to collect and visualize global information system (GIS)-based air quality data overlayed with environmental variables to support air quality management measures. Spatiotemporal analyses of ML-derived data from Bucheon, Korea, confirmed that particulate and gaseous pollutant concentrations were high during typical commuting hours, at intersections, and at a specially managed road. During commuting hours, the maximum PM10 concentration reached 200.7 µg/m3 in the Nae-dong, Gyeongin-ro, and Ojeong-dong ready-mix concrete complex areas, and the maximum PM2.5 concentration was 161.7 µg/m3. The maximum NOx, NO2, and NO levels of 1.34 ppm, 0.18 ppm, and 1.18 ppm, respectively, were also detected during commuting hours. These findings support the need for targeted management of air pollution in this region, and highlight the benefit of comprehensively comparing road levels, driving speed, and traffic levels when identifying hotspots of air pollution. Such analyses will contribute to the development of air quality management measures customized to regional characteristics.

Time-sequential fibroblast-to-myofibroblast transition in elastin-variable 3D hydrogel environments by collagen networks.

BACKGROUND: Fibrosis plays an important role in both normal physiological and pathological phenomena as fibroblasts differentiate to myofibroblasts. The activation of fibroblasts is determined through interactions with the surrounding extracellular matrix (ECM). However, how this fibroblast-to-myofibroblast transition (FMT) is regulated and affected by elastin concentration in a three-dimensional (3D) microenvironment has not been investigated. METHODS: We developed an insoluble elastin-gradient 3D hydrogel system for long-lasting cell culture and studied the molecular mechanisms of the FMT in embedded cells by nanoflow LC-MS/MS analysis along with validation through real-time PCR and immunofluorescence staining. RESULTS: By optimizing pH and temperature, four 3D hydrogels containing fibroblasts were successfully fabricated having elastin concentrations of 0, 20, 50, and 80% in collagen. At the low elastin level (20%), fibroblast proliferation was significantly increased compared to others, and in particular, the FMT was clearly observed in this condition. Moreover, through mass spectrometry of the hydrogel environment, it was confirmed that differentiation proceeded in two stages. In the early stage, calcium-dependent proteins including calmodulin and S100A4 were highly associated. On the other hand, in the late stage after several passages of cells, distinct markers of myofibroblasts were presented such as morphological changes, increased production of ECM, and increased α-SMA expression. We also demonstrated that the low level of elastin concentration induced some cancer-associated fibroblast (CAF) markers, including PDGFR-ß, and fibrosis-related disease markers, including THY-1. CONCLUSION: Using our developed 3D elastin-gradient hydrogel system, we evaluated the effect of different elastin concentrations on the FMT. The FMT was induced even at a low concentration of elastin with increasing CAF level via calcium signaling. With this system, we were able to analyze varying protein expressions in the overall FMT process over several cellular passages. Our results suggest that the elastin-gradient system employing nonlinear optics imaging provides a good platform to study activated fibroblasts interacting with the microenvironment, where the ECM plays a pivotal role.

Evaluation of the effect of particulate matter on construction accidents using relative probability.

PM10 is known to have a great adverse effect on the human body. However, there is a lack of research analyzing the impact of PM10 on the occurrence of accidents. Accordingly, the purpose of this study is to analyze the correlation between PM10 and accidents in the construction industry and to present a new concentration group to manage accidents caused by PM10 in the construction industry. This study was conducted in the following four stages. (i) collection of data, (ii) classification of data, (iii) relative probability analysis, and (iv) modified PM10 group classification. The main results of this study are as follows. When the frequency analysis of the traditional method was conducted, 3,721 accidents occurred at a PM10 concentration of 32 µg/m3. However, as a result of the relative probability analysis presented in this study, it was confirmed that the relative accident probability increased as the PM10 concentration increased. In addition, the current PM10 concentration is presented by the WHO in six groups from a health perspective. However, in this study, the newly proposed PM10 group was classified into three groups from the perspective of the probability of construction accidents. The group proposed in this study is not from a health perspective but a group for managing construction site accidents. The contribution of this study was to confirm that PM10 also affects accidents occurring at construction sites, and the impact of PM10 on accidents was quantitatively analyzed through the relative probability analysis presented in this study.

Facet-Controlled Cu2O Support Enhances Catalytic Activity of Pt Nanoparticles for CO Oxidation.

The metal-support interaction plays a crucial role in determining the catalytic activity of supported metal catalysts. Changing the facet of the support is a promising strategy for catalytic control via constructing a well-defined metal-support nanostructure. Herein, we developed cubic and octahedral Cu2O supports with (100) and (111) facets terminated, respectively, and Pt nanoparticles (NPs) were introduced. The in situ characterizations revealed the facet-dependent encapsulation of the Pt NPs by a CuO layer due to the oxidation of the Cu2O support during the CO oxidation reaction. The CuO layer on Pt at cubic Cu2O (Pt/c-Cu2O) significantly enhanced catalytic performance, while the thicker CuO layer on Pt at octahedral Cu2O suppressed CO conversion. The formation of a thin CuO layer is attributed to the dominant Pt-O-Cu bond at the Pt/c-Cu2O interface, which suppresses the adsorption of oxygen molecules. This investigation provides insight into designing high-performance catalysts via engineering the interface interaction.

Capacity-achieving symbol distributions for directly modulated laser and direct detection systems.

We investigate the capacity-achieving symbol distributions for directly modulated laser (DML) and direct-detection (DD) systems utilizing probabilistic constellation shaped pulse amplitude modulation formats. DML-DD systems utilize a bias tee to feed the DC bias current and AC-coupled modulation signals. Also, an electrical amplifier is commonly utilized to drive the laser. Thus, most DML-DD systems are subject to the constraints of the average optical power and peak electrical amplitude. We compute the channel capacity of the DML-DD systems under these constraints by using the Blahut-Arimoto algorithm to obtain the capacity-achieving symbol distributions. We also carry out experimental demonstration to verify our computation results. We show that the probabilistic constellation shaping (PCS) technique marginally increases the capacity of DML-DD system when the optical modulation index (OMI) is less than 1. However, the PCS technique allows us to increase the OMI larger than 1 without clipping distortions. As a result, we can increase the capacity of DML-DD system by using the PCS technique in comparison with the uniformly distributed signals.

SUMO1 degrader induces ER stress and ROS accumulation through deSUMOylation of TCF4 and inhibition of its transcription of StarD7 in colon cancer.

Small molecule degraders of small ubiquitin-related modifier 1 (SUMO1) induce SUMO1 degradation in colon cancer cells and inhibits the cancer cell growth; however, it is unclear how SUMO1 degradation leads to the anticancer activity of the degraders. Genome-wide CRISPR-Cas9 knockout screen has identified StAR-related lipid transfer domain containing 7 (StarD7) as a critical gene for the degrader's anticancer activity. Here, we show that both StarD7 mRNA and protein are overexpressed in human colon cancer and its knockout significantly reduces colon cancer cell growth and xenograft progression. The treatment with the SUMO1 degrader lead compound HB007 reduces StarD7 mRNA and protein levels and increases endoplasmic reticulum (ER) stress and reactive oxygen species (ROS) production in colon cancer cells and three-dimensional (3D) organoids. The study further provides a novel mechanism of the compound anticancer activity that SUMO1 degrader-induced decrease of StarD7 occur through degradation of SUMO1, deSUMOylation and degradation of T cell-specific transcription 4 (TCF4) and thereby inhibition of its transcription of StarD7 in colon cancer cells, 3D organoids and patient-derived xenografts (PDX).

Medicare Advantage Enrollment Among Beneficiaries With End-Stage Renal Disease in the First Year of the 21st Century Cures Act.

Importance: Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans. The 21st Century Cures Act permitted these beneficiaries to enroll in MA plans effective January 2021. Objective: To examine changes in MA enrollment among Medicare beneficiaries with ESRD after enactment of the 21st Century Cures Act overall and by race or ethnicity and dual-eligible status. Design, Setting, and Participants: This cross-sectional time-trend study used data from Medicare beneficiaries with ESRD (both kidney transplant recipients and those undergoing dialysis) between January 2019 and December 2021. Data were analyzed between June and October 2022. Exposures: 21st Century Cures Act. Main Outcomes and Measures: Primary outcomes were the proportion of Medicare beneficiaries with prevalent ESRD who switched from traditional Medicare to MA between 2020 and 2021 and those with incident ESRD who newly enrolled in MA in 2021. Individuals who stayed in traditional Medicare were enrolled in 2020 and 2021 and those who switched to MA were enrolled in traditional Medicare in 2020 and MA in 2021. Results: Among 575 797 beneficiaries with ESRD in 2020 or 2021 (mean [SD] age, 64.7 [14.2] years, 42.2% female, 34.0% Black, and 7.7% Hispanic or Latino), the proportion of beneficiaries enrolled in MA increased from 24.8% (December 2020) to 37.4% (December 2021), a relative change of 50.8%. The largest relative increases in MA enrollment were among Black (72.8% relative increase), Hispanic (44.8%), and dual-eligible beneficiaries with ESRD (73.6%). Among 359 617 beneficiaries with TM and prevalent ESRD in 2020, 17.6% switched to MA in 2021. Compared with individuals who stayed in traditional Medicare, those who switched to MA had modestly more chronic conditions (6.3 vs 6.1; difference, 0.12 conditions [95% CI, 0.10-0.16]) and similar nondrug spending in 2020 (difference, $509 [95% CI, -$58 to $1075]) but were more likely to be Black (difference, 19.5 percentage points [95% CI, 19.1-19.9]) and have dual Medicare-Medicaid eligibility (difference, 20.8 percentage points [95% CI, 20.4-21.2]). Among beneficiaries who were newly eligible for Medicare ESRD benefits in 2021, 35.2% enrolled in MA. Conclusions and Relevance: Results suggest that increases in MA enrollment among Medicare beneficiaries with ESRD were substantial the first year after the 21st Century Cures Act, particularly among Black, Hispanic, and dual-eligible individuals. Policy makers and MA plans may need to assess network adequacy, disenrollment, and equity of care for beneficiaries who enrolled in MA.

Tuning CO2 Hydrogenation Selectivity through Reaction-Driven Restructuring on Cu-Ni Bimetal Catalysts.

Tuning the selectivity of CO2 hydrogenation is of significant scientific interest, especially using nickel-based catalysts. Fundamental insights into CO2 hydrogenation on Ni-based catalysts demonstrate that CO is a primary intermediate, and product selectivity is strongly dependent on the oxidation state of Ni. Therefore, modifying the electronic structure of the nickel surface is a compelling strategy for tuning product selectivity. Herein, we synthesized well dispersed Cu-Ni bimetallic nanoparticles (NPs) using a simple hydrothermal method for CO selective CO2 hydrogenation. A detailed study on the monometallic (Ni and Cu) and bimetallic (CuxNi1-x) catalysts supported on γ-Al2O3 was performed to increase CO selectivity while maintaining the high reaction rate. The Cu0.5Ni0.5/γ-Al2O3 catalyst shows a high CO2 conversion and more CO product selectivity than its monometallic counterparts. The surface electronic and geometric structure of Cu0.5Ni0.5 bimetallic NPs was studied using ambient pressure X-ray photoelectron spectroscopy (AP-XPS) and in situ diffuse reflectance infrared Fourier-transform spectroscopy under reaction conditions. The Cu core atoms migrate toward the surface, resulting in the restructuring of the Cu@Ni core-shell structure to a Cu-Ni alloy during the reaction and functioning as the active site by enhancing CO desorption. A systematic correlation is obtained between catalytic activity from a continuous fixed-bed flow reactor and the surface electronic structural details derived from AP-XPS results, establishing the structure-activity relationship. This investigation contributes to providing a strategy for controlling CO2 hydrogenation selectivity by modifying the surface structure of bimetallic NP catalysts.

Effects of High-Intensity Exercise on Physiological Indicators of Recovery Period by Wearing Face Masks of Elite Athletes.

Athletes need to maintain the necessary physical conditioning for sports performance while wearing face masks to reduce the risk of virus transmission during training and competition during the COVID-19 situation. The quantitative and physiological effects of face masks on exercise capacity needs to be reported. The purpose of this study was to evaluate elite athletes to quantify, in detail, the effect of a KF94 face mask on changes in lactic acid during recovery after high-intensity aerobic exercise. Thirteen elite soft tennis athletes were recruited. A crossover design was used to examine the effects of using a disposable KF94 face mask compared with not masking during exercise. The participants completed a shuttle run test experiment two times during a 3-day period, including 5−10 min of warmup according to their personal preferences. The lactic acid concentration at 20 min of recovery after maximum exercise was 5.98 ± 1.53 mM/L without a mask and 7.61 ± 1.85 mM/L with a KF94 mask (p < 0.001). The maximum laps of shuttle run tests were 101.5 ± 22.5 laps without a mask and 94.2 ± 20.2 laps with a KF94 mask (p < 0.001). Intense exercise after wearing quarantine masks reduces the maximum aerobic exercise ability and decreases the ability to recover lactic acid.

Effect of Water Vapor on Oxidation Processes of the Cu(111) Surface and Sublayer.

Copper-based catalysts have different catalytic properties depending on the oxidation states of Cu. We report operando observations of the Cu(111) oxidation processes using near-ambient pressure scanning tunneling microscopy (NAP-STM) and near-ambient pressure X-ray photoelectron spectroscopy (NAP-XPS). The Cu(111) surface was chemically inactive to water vapor, but only physisorption of water molecules was observed by NAP-STM. Under O2 environments, dry oxidation started at the step edges and proceeded to the terraces as a Cu2O phase. Humid oxidation of the H2O/O2 gas mixture was also promoted at the step edges to the terraces. After the Cu2O covered the surface under humid conditions, hydroxides and adsorbed water layers formed. NAP-STM observations showed that Cu2O was generated at lower steps in dry oxidation with independent terrace oxidations, whereas Cu2O was generated at upper steps in humid oxidation. The difference in the oxidation mechanisms was caused by water molecules. When the surface was entirely oxidized, the diffusion of Cu and O atoms with a reconstruction of the Cu2O structures induced additional subsurface oxidation. NAP-XPS measurements showed that the Cu2O thickness in dry oxidation was greater than that in humid oxidation under all pressure conditions.

CT-Loc: Cross-domain visual localization with a channel-wise transformer.

We tackle the cross-domain visual localization problem of estimating camera position and orientation from real images without three-dimensional (3D) spatial mapping or modeling. Recent studies have shown suboptimal performance in this task owing to the photometric and geometric differences between synthetic and real images. In this study, we present a deep learning approach that uses a channel-wise transformer localization (CT-Loc) framework. Inspired by the human behavior of looking for structural landmarks to estimate one's location, CT-Loc encodes the most salient features of task-relevant objects in target scenes. To evaluate the efficacy of the proposed method in a real-world application, we built a complex and large-scale dataset of the interior of the mechanical room during operations and conducted extensive performance comparisons with the publicly available state-of-the-art University of Melbourne Corridor and Virtual KITTI 2 datasets. Compared with the otherwise best-performing BIM-PoseNet indoor camera localization model, our method significantly reduces position and orientation errors through the application of attention weights and saliency maps while also learning only the visual structural patterns (e.g., floors and doors) that are most relevant to localization tasks. Our model successfully ignores uninformative objects. This approach yields higher-level robust camera-pose regression localization results without requiring prebuilt maps. The code is available at https://github.com/kdaeho27/CT-Loc.

Risks of complicated acute appendicitis in patients with psychiatric disorders.

BACKGROUND: Acute appendicitis often presents with vague abdominal pain, which fosters diagnostic challenges to clinicians regarding early detection and proper intervention. This is even more problematic with individuals with severe psychiatric disorders who have reduced sensitivity to pain due to long-term or excessive medication use or disturbed bodily sensation perceptions. This study aimed to determine whether psychiatric disorder, psychotropic prescription, and treatment compliance increase the risks of complicated acute appendicitis. METHODS: The diagnosis records of acute appendicitis from four university hospitals in Korea were investigated from 2002 to 2020. A total of 47,500 acute appendicitis-affected participants were divided into groups with complicated and uncomplicated appendicitis to determine whether any of the groups had more cases of psychiatric disorder diagnoses. Further, the ratio of complicated compared to uncomplicated appendicitis in the mentally ill group was calculated regarding psychotropic dose, prescription duration, and treatment compliance. RESULTS: After adjusting for age and sex, presence of psychotic disorder (odds ratio [OR]: 1.951; 95% confidence interval [CI]: 1.218-3.125), and bipolar disorder (OR: 2.323; 95% CI: 1.194-4.520) was associated with a higher risk of having complicated appendicitis compared with absence of psychiatric disorders. Patients who are taking high-daily-dose antipsychotics, regardless of prescription duration, show high complicated appendicitis risks; High-dose antipsychotics for < 1 year (OR: 1.896, 95% CI: 1.077-3.338), high-dose antipsychotics for 1-5 years (OR: 1.930, 95% CI: 1.144-3.256). Poor psychiatric outpatient compliance was associated with a high risk of complicated appendicitis (OR: 1.664, 95% CI: 1.014-2.732). CONCLUSIONS: This study revealed a close relationship in the possibility of complicated appendicitis in patients with severe psychiatric disorders, including psychotic and bipolar disorders. The effect on complicated appendicitis was more remarkable by the psychiatric disease entity itself than by psychotropic prescription patterns. Good treatment compliance and regular visit may reduce the morbidity of complicated appendicitis in patients with psychiatric disorders.

dTMP imbalance through thymidylate 5'-phosphohydrolase activity induces apoptosis in triple-negative breast cancers.

Immunotherapy has a number of advantages over traditional anti-tumor therapy but can cause severe adverse reactions due to an overactive immune system. In contrast, a novel metabolic treatment approach can induce metabolic vulnerability through multiple cancer cell targets. Here, we show a therapeutic effect by inducing nucleotide imbalance and apoptosis in triple negative breast cancer cells (TNBC), by treating with cytosolic thymidylate 5'-phosphohydrolase (CT). We show that a sustained consumption of dTMP by CT could induce dNTP imbalance, leading to apoptosis as tricarboxylic acid cycle intermediates were depleted to mitigate this imbalance. These cytotoxic effects appeared to be different, depending on substrate specificity of the 5' nucleotide or metabolic dependency of the cancer cell lines. Using representative TNBC cell lines, we reveal how the TNBC cells were affected by CT-transfection through extracellular acidification rate (ECAR)/oxygen consumption rate (OCR) analysis and differential transcription/expression levels. We suggest a novel approach for treating refractory TNBC by an mRNA drug that can exploit metabolic dependencies to exacerbate cell metabolic vulnerability.

Medicaid Expansion and Medicare-Financed Hospitalizations Among Adult Patients With Incident Kidney Failure.

Importance: Although Medicare provides health insurance coverage for most patients with kidney failure in the US, Medicare beneficiaries who initiate dialysis without supplemental coverage are exposed to substantial out-of-pocket costs. The availability of expanded Medicaid coverage under the Patient Protection and Affordable Care Act (ACA) for adults with kidney failure may improve access to care and reduce Medicare-financed hospitalizations after dialysis initiation. Objective: To examine the implications of the ACA's Medicaid expansion for Medicare-financed hospitalizations, health insurance coverage, and predialysis nephrology care among Medicare-covered adults aged 19 to 64 years with incident kidney failure in the first year after initiating dialysis. Design, Setting, and Participants: This cross-sectional study used a difference-in-differences approach to assess Medicare-financed hospitalizations among adults aged 19 to 64 years who initiated dialysis between January 1, 2010, and December 31, 2018, while covered by Medicare Part A (up to 5 years postexpansion). Data on patients were obtained from the Renal Management Information System's End Stage Renal Disease Medical Evidence Report, which includes data for all patients initiating outpatient maintenance dialysis regardless of health insurance coverage, treatment modality, or citizenship status, and these data were linked with claims data from the Medicare Provider Analysis and Review. Data were analyzed from January to August 2022. Exposure: Living in a Medicaid expansion state. Main Outcomes and Measures: Primary outcomes were number of Medicare-financed hospitalizations and hospital days in the first 3 months, 6 months, and 12 months after dialysis initiation. Secondary outcomes included dual Medicare and Medicaid coverage at 91 days after dialysis initiation and the presence of an arteriovenous fistula or graft at dialysis initiation for patients undergoing hemodialysis. Results: The study population included 188 671 adults, with 97 071 living in Medicaid expansion states (mean [SD] age, 53.4 [9.4] years; 58 329 men [60.1%]) and 91 600 living in nonexpansion states (mean [SD] age, 53.0 [9.6] years; 52 677 men [57.5%]). In the first 3 months after dialysis initiation, Medicaid expansion was associated with a significant decrease in Medicare-financed hospitalizations (-4.24 [95% CI, -6.70 to -1.78] admissions per 100 patient-years; P = .001) and hospital days (-0.73 [95% CI, -1.08 to -0.39] days per patient-year; P < .001), relative reductions of 8% for both outcomes. Medicaid expansion was associated with a 2.58-percentage point (95% CI, 0.88-4.28 percentage points; P = .004) increase in dual Medicare and Medicaid coverage at 91 days after dialysis initiation and a 1.65-percentage point (95% CI, 0.31-3.00 percentage points; P = .02) increase in arteriovenous fistula or graft at initiation. Conclusions and Relevance: In this cross-sectional study with a difference-in-differences analysis, the ACA's Medicaid expansion was associated with decreases in Medicare-financed hospitalizations and hospital days and increases in dual Medicare and Medicaid coverage. These findings suggest favorable spillover outcomes of Medicaid expansion to Medicare-financed care, which is the primary payer for patients with kidney failure.

Intravesical Recurrence after Radical Nephroureterectomy in Patients with Upper Tract Urothelial Carcinoma Is Associated with Flexible Diagnostic Ureteroscopy, but Not with Rigid Diagnostic Ureteroscopy.

(1) Background: We assessed the impact of diagnostic ureteroscopy (URS) on intravesical recurrence (IVR) following radical nephroureterectomy (RNU) for upper tract urothelial carcinoma according to the type of URS. (2) Methods: Data on 491 consecutive patients who underwent RNU at two institutions between 2016 and 2019 were retrospectively reviewed. The study population was classified according to the type of URS performed before RNU as follows: non-URS, rigid URS, and flexible URS. The study outcome was IVR occurring within 1 year of RNU. Univariable and multivariable Cox proportional hazards models were used to estimate the risk of IVR. (3) Results: Altogether, 396 patients were included for analysis. Rigid and flexible URS were performed in 178 (45%) and 111 (28%) patients, respectively, while 107 (27%) patients did not undergo URS. IVR was identified in 99 (25%) patients. Multivariable Cox regression analysis revealed that the flexible URS group was significantly associated with increased IVR, compared to the non-URS group (HR = 1.807, p = 0.0416). No significant difference in IVR was observed between the non-URS and rigid URS groups (HR = 1.301, p = 0.3388). (4) Conclusions: In patients with UTUC undergoing RNU, rigid URS may not increase the risk of IVR, whereas flexible URS appears to be associated with a higher risk of IVR.