Association between hospital private equity acquisition and outcomes of acute medical conditions among Medicare beneficiaries

Importance: As private equity (PE) acquisitions of short-term acute care hospitals (ACHs) continue, their impact on the care of medically vulnerable older adults remains largely unexplored. Objective: To investigate the association between PE acquisition of ACHs and access to care, patient outcomes, and spending among Medicare beneficiaries hospitalized with acute medical conditions. Design, Setting, and Participants: This cross-sectional study used a generalized difference-in-differences approach to compare 21 091 222 patients admitted to PE-acquired vs non-PE-acquired short-term ACHs between January 1, 2001, and December 31, 2018, at least 3 years before to 3 years after PE acquisition. The analysis was conducted between December 28, 2020, and February 1, 2022. Differences were estimated using both facility and hospital service area fixed effects. To assess the robustness of findings, regressions were reestimated after including fixed effects of patient county of origin to account for geographic differences in underlying health risks. Two subset analyses were also conducted: (1) an analysis including only hospitals in hospital referral regions with at least 1 PE acquisition and (2) an analysis stratified by participation in the Hospital Corporation of America 2006 acquisition. The study included Medicare beneficiaries 66 years and older who were hospitalized with 1 of 5 acute medical conditions: acute myocardial infarction (AMI), acute stroke, chronic obstructive pulmonary disease exacerbation, congestive heart failure exacerbation, and pneumonia. Exposures: Acquisition of hospitals by PE firms. Main Outcomes and Measures: Comorbidity burden (measured by Elixhauser comorbidity score), hospital length of stay, in-hospital mortality, 30-day mortality, 30-day readmission, and 30-day episode payments. Results: Among 21 091 222 total Medicare beneficiaries admitted to ACHs between 2001 and 2018, 20 431 486 patients received care at non-PE-acquired hospitals, and 659 736 received care at PE-acquired hospitals. Across all admissions, the mean (SD) age was 79.45 (7.95) years; 11 727 439 patients (55.6%) were male, and 4 550 012 patients (21.6%) had dual insurance; 2 996 560 (14.2%) patients were members of racial or ethnic minority groups, including 2 085 128 [9.9%] Black and 371 648 [1.8%] Hispanic; 18 094 662 patients (85.8%) were White. Overall, 3 083 760 patients (14.6%) were hospitalized with AMI, 2 835 777 (13.4%) with acute stroke, 3 674 477 (17.4%) with chronic obstructive pulmonary disease exacerbation, 5 868 034 (27.8%) with congestive heart failure exacerbation, and 5 629 174 (26.7%) with pneumonia. Comorbidity burden decreased slightly among patients admitted with acute stroke (difference, -0.04 SDs; 95% CI, -0.004 to -0.07 SDs) at acquired hospitals compared with nonacquired hospitals but was unchanged across the other 4 conditions. Among patients with AMI, a greater decrease in in-hospital mortality was observed in PE-acquired hospitals compared with non-PE-acquired hospitals (difference, -1.14 percentage points, 95% CI, -1.86 to -0.42 percentage points). In addition, a greater decrease in 30-day mortality (difference, -1.41 percentage points; 95% CI, -2.26 to -0.56 percentage points) was found at acquired vs nonacquired hospitals. However, 30-day spending and readmission rates remained unchanged across all conditions. The extent and directionality of estimates were preserved across all robustness assessments and subset analyses. Conclusions and Relevance: In this cross-sectional study using a difference-in-differences approach, PE acquisition had no substantial association with the patient-level outcomes examined, although it was associated with a moderate improvement in mortality among Medicare beneficiaries hospitalized with AMI

Functional modulation of LHCSR1 protein from Physcomitrella patens by zeaxanthin binding and low pH

Light harvesting for oxygenic photosynthesis is regulated to prevent the formation of harmful photoproducts by activation of photoprotective mechanisms safely dissipating the energy absorbed in excess. Lumen acidification is the trigger for the formation of quenching states in pigment binding complexes. With the aim to uncover the photoprotective functional states responsible for excess energy dissipation in green algae and mosses, we compared the fluorescence dynamic properties of the light-harvesting complex stress-related (LHCSR1) protein, which is essential for fast and reversible regulation of light use efficiency in lower plants, as compared to the major LHCII antenna protein, which mainly fulfills light harvesting function. Both LHCII and LHCSR1 had a chlorophyll fluorescence yield and lifetime strongly dependent on detergent concentration but the transition from long- to short-living states was far more complete and fast in the latter. Low pH and zeaxanthin binding enhanced the relative amplitude of quenched states in LHCSR1, which were characterized by the presence of 80 ps fluorescence decay components with a red-shifted emission spectrum. We suggest that energy dissipation occurs in the chloroplast by the activation of 80 ps quenching sites in LHCSR1 which spill over excitons from the photosystem II antenna system

Functional analysis of photosynthetic pigment binding complexes in the green alga Haematococcus pluvialis reveals distribution of astaxanthin in Photosystems

Astaxanthin is a ketocarotenoid produced by photosynthetic microalgae. It is a pigment of high industrial interest in acquaculture, cosmetics, and nutraceutics due to its strong antioxidant power. Haematococcus pluvialis, a fresh-water microalga, accumulates high levels of astaxanthin upon oxidative stress, reaching values up to 5% per dry weight. H. pluvialis accumulates astaxanthin in oil droplets in the cytoplasm, while the chloroplast volume is reduced. In this work, we investigate the biochemical and spectroscopic properties of the H. pluvialis pigment binding complexes responsible for light harvesting and energy conversion. Our findings demonstrate that the main features of chlorophyll and carotenoid binding complexes previously reported for higher plants or Chlamydomonas reinhardtii are preserved under control conditions. Transition to astaxanthin rich cysts however leads to destabilization of the Photosystems. Surprisingly, astaxanthin was found to be bound to both Photosystem I and II, partially substituting β-carotene, and thus demonstrating possible astaxanthin biosynthesis in the plastids or transport from the cytoplasm to the chloroplast. Astaxanthin binding to Photosystems does not however improve their photoprotection, but rather reduces the efficiency of excitation energy transfer to the reaction centers. We thus propose that astaxanthin binding partially destabilizes Photosystem I and II

LHCII can substitute for LHCI as an antenna for photosystem i but with reduced light-harvesting capacity

Light-harvesting complexes (LHCs) are major constituents of the antenna systems in higher plant photosystems. Four Lhca subunits are tightly bound to the photosystem I (PSI) core complex, forming its outer antenna moiety called LHCI. The Arabidopsis thaliana mutant δLhca lacks all Lhca1-4 subunits and compensates for its decreased antenna size by binding LHCII trimers, the main constituent of the photosystem II antenna system, to PSI. In this work we have investigated the effect of LHCI/LHCII substitution by comparing the light harvesting and excitation energy transfer efficiency properties of PSI complexes isolated from δLhca mutants and from the wild type, as well as the consequences for plant growth. We show that the excitation energy transfer efficiency was not compromised by the substitution of LHCI with LHCII but a significant reduction in the absorption cross-section was observed. The absence of LHCI subunits in PSI thus significantly limits light harvesting, even on LHCII binding, inducing, as a consequence, a strong reduction in growth

Evaluación de las posibilidades de internacionalización de la carrera de Especialización en Cirugía Plástica, Facultad de Medicina de la Universidad de Buenos Aires con sede en el Hospital Italiano de Buenos Aires. ¿Es posible con el programa actual?

Fil: Cerullo, Carlos Marcelo. Universidad de Buenos Aires. Secretaría de Asuntos Académicos. Buenos Aires, ArgentinaEl presente ensayo analiza las posibilidades de acreditación internacional de la carrera de\nespecialización en Cirugía Plástica de la Universidad de Buenos Aires (UBA) con sede en el\nHospital Italiano de Buenos Aires (HIBA).\nLa internacionalización de la Educación Superior permite la creación de espacios de\nconvergencia de programas, con el fin de que se acrediten para asegurar su calidad a través\nde estándares compartidos regional y globalmente, a la vez que se respetan los valores\nlocales culturales y se respeta la pertinencia de la instituciones a la sociedad en la que se\ndesarrollan. De esta forma, se facilita la movilidad de docentes, investigadores , estudiantes\ny otros actores de la Educación Superior, y el intercambio promueve el mejoramiento en\ncada participante del proceso.\nEl objetivo principal del ensayo es comparar la carrera de especialización a analizar con\nvariables que caracterizan la formación en la especialidad de Cirugía Plástica en otros\npaíses de la región de Latinoamérica, Europa y Estados Unidos, a través de la identificación\nde estándares que permiten la acreditación en los respectivos países.\nPara ello, se revisaron programas de los países de las regiones mencionadas, publicaciones\nespecíficas sobre la especialización en Cirugía Plástica, y se visitaron sitios oficiales\nrelacionados con la acreditación de la Educación Superior. Se compararon parámetros\nobjetivos como requisitos y modalidad de ingreso, duración de los programas, prácticas\nrequeridas, necesidad de investigación y condiciones de evaluación para la aprobación de la\ncarrera con respecto a programas de Europa, LatinoAmérica y Estados Unidos. Se halló\nque los estándares educativos regionales e internacionales con los cuales comparar la\ncarrera no se encontraban explícitos adecuadamente, lo que denota una situación precaria\ninstitucional en los organismos supranacionales y una diversidad en la estructura de los\nprogramas de formación, aún en la misma región. A pesar de ello, se concluyó que la\ncarrera analizada presenta similitudes que la posicionan como susceptible de una\nacreditación internacional a nivel regional y global. Finalmente, el análisis permite establecer\nla implementación de modificaciones para su mejoramiento

Validation of the 8th Edition American Joint Commission on Cancer (AJCC) Gallbladder Cancer Staging System: Prognostic Discrimination and Identification of Key Predictive Factors

The scope of our study was to compare the predictive ability of American Joint Committee on Cancer (AJCC) 7th and 8th edition in gallbladder carcinoma (GBC) patients, investigate the effect of AJCC 8th nodal status on the survival, and identify risk factors associated with the survival after N reclassification using the National Cancer Database (NCDB) in the period 2005–2015. The cohort consisted of 7743 patients diagnosed with GBC; 202 patients met the criteria for reclassification and were denoted as stage ≥III by AJCC 7th and 8th edition criteria. Overall survival concordance indices were similar for patients when classified by AJCC 8th (OS c-index: 0.665) versus AJCC 7th edition (OS c-index: 0.663). Relative mortality was higher within strata of T1, T2, and T3 patients with N2 compared with N1 stage (T1 HR: 2.258, p < 0.001; T2 HR: 1.607, p < 0.001; Τ3 HR: 1.306, p < 0.001). The risk of death was higher in T1–T3 patients with Nx compared with N1 stage (T1 HR: 1.281, p = 0.043, T2 HR: 2.221, p < 0.001, T3 HR: 2.194, p < 0.001). In patients with AJCC 8th edition stage ≥IIIB GBC and an available grade, univariate analysis showed that higher stage, Charlson–Deyo score ≥ 2, higher tumor grade, and unknown nodal status were associated with an increased risk of death, while year of diagnosis after 2013, academic center, chemotherapy. and radiation therapy were associated with decreased risk of death. Chemotherapy and radiation therapy were associated with decreased risk of death in patients with T3–T4 and T2–T4 GBC, respectively. In conclusion, the updated AJCC 8th GBC staging system was comparable to the 7th edition, with the recently implemented changes in N classification assessment failing to improve the prognostic performance of the staging system. Further prospective studies are needed to validate the T2 stage subclassification as well as to clarify the association, if any is actually present, between advanced N staging and increased risk of death in patients of the same T stage

Regulation of photosystem I light harvesting by zeaxanthin.

In oxygenic photosynthetic eukaryotes, the hydroxylated carotenoid zeaxanthin is produced from preexisting violaxanthin upon exposure to excess light conditions. Zeaxanthin binding to components of the photosystem II (PSII) antenna system has been investigated thoroughly and shown to help in the dissipation of excess chlorophyll-excited states and scavenging of oxygen radicals. However, the functional consequences of the accumulation of the light-harvesting complex I (LHCI) proteins in the photosystem I (PSI) antenna have remained unclarified so far. In this work we investigated the effect of zeaxanthin binding on photoprotection of PSI-LHCI by comparing preparations isolated from wild-type Arabidopsis thaliana (i.e., with violaxanthin) and those isolated from the A. thaliana nonphotochemical quenching 2 mutant, in which violaxanthin is replaced by zeaxanthin. Time-resolved fluorescence measurements showed that zeaxanthin binding leads to a previously unrecognized quenching effect on PSI-LHCI fluorescence. The efficiency of energy transfer from the LHCI moiety of the complex to the PSI reaction center was down-regulated, and an enhanced PSI resistance to photoinhibition was observed both in vitro and in vivo. Thus, zeaxanthin was shown to be effective in inducing dissipative states in PSI, similar to its well-known effect on PSII. We propose that, upon acclimation to high light, PSI-LHCI changes its light-harvesting efficiency by a zeaxanthin-dependent quenching of the absorbed excitation energy, whereas in PSII the stoichiometry of LHC antenna proteins per reaction center is reduced directly

Awareness of racial/ethnic disparities in surgical outcomes and care: Factors affecting acknowledgment and action

Background: Studies have demonstrated racial/ethnic disparities in surgical outcomes and care. Surgeon awareness and its association with institutional action remain unclear. The study sought to assess surgeons\u27 awareness of racial/ethnic disparities, ascertain whether demographic and practice factors influence acknowledgement of disparities, and determine whether surgeons are seeking to mitigate disparities. Methods: Anonymous online survey was administered to a random sample of American College of Surgeons (ACS) general surgeons (July 2013 to March 2014). Responses were weighted for nonresponse and risk-adjusted using logistic regression. Results: 172 surgeons completed the survey. Levels of acknowledged disparities were low. Less than one half reported institutional efforts to address disparities, and less than one fourth had taken efforts to investigate disparities in their personal practice. Several respondent factors including Academic Medical Center affiliation, awareness of the ACS statement on optimal access, and year of medical school graduation significantly associated with expressed acknowledgment of disparities. Conclusions: Such associations speak to the need for continued efforts to promote enhanced provider awareness and participation. As the field of surgical disparities moves from understanding to action, we must acknowledge the contributing role that providers pla