Effects of a Population Health Community-Based Palliative Care Program on Cost and Utilization.

Background: New population health community-based models of palliative care can result in more compassionate, affordable, and sustainable high-quality care. Objectives: We evaluated utilization and cost outcomes of a standardized, population health community-based palliative care program provided by nurses and social workers. Design: We conducted a retrospective propensity-adjusted study to quantify cost savings and resource utilization associated with a community-based palliative care program. We analyzed claims data from a Medicare Advantage (MA) plan and used a proprietary predictive model to identify 804 members at high risk for overmedicalized end-of-life care. We enrolled 204 members in the palliative care program and compared them with 600 who received standard, telephonic, health plan case management. We excluded members with fewer than two months of enrolled experience or those with insufficient data for analysis, leaving 176 members in the study group and 570 in the control group for evaluation. We compared differences in utilization and costs (medical and pharmacy), hospital admissions, bed days (acute and intensive care unit [ICU]), and emergency department visits. Setting/Subjects: A 30,000-member MA plan and a health system in Central Ohio between October 2015 and June 2016. Results: Members who received community-based palliative care showed a statistically significant 20% reduction in total medical costs ($619 per enrolled member per month), 38% reduction in ICU admissions, 33% reduction in hospital admissions, and 12% reduction in hospital days. Conclusion: A structured nurse and social work model of community-based palliative care using a predictive model to identify MA candidates for intervention can reduce utilization and medical costs.

Biocatalytic Routes to Enantiomerically Enriched Dibenz[c,e]azepines.

Biocatalytic retrosynthetic analysis of dibenz[c,e]azepines has highlighted the use of imine reductase (IRED) and ω-transaminase (ω-TA) biocatalysts to establish the key stereocentres of these molecules. Several enantiocomplementary IREDs were identified for the synthesis of (R)- and (S)-5-methyl-6,7-dihydro-5H-dibenz[c,e]azepine with excellent enantioselectivity, by reduction of the parent imines. Crystallographic evidence suggests that IREDs may be able to bind one conformer of the imine substrate such that, upon reduction, the major product conformer is generated directly. ω-TA biocatalysts were also successfully employed for the production of enantiopure 1-(2-bromophenyl)ethan-1-amine, thus enabling an orthogonal route for the installation of chirality into dibenz[c,e]azepine framework.

An assessment of the concentration-related prognostic value of cardiac troponin I following acute coronary syndrome.

In 2004 the British Cardiac Society redefined myocardial infarction by cardiac troponin I (cTnI) concentration: ≤ 0.06 µg/L (unstable angina), >0.06 to < 0.5 µg/L (myocardial necrosis), and ≥ 0.5 µg/L (myocardial infarction). We investigated the effects of this classification on all-cause mortality in 1,285 patients from the Evaluation of the Methods and Management of Acute Coronary Events (EMMACE)-2 registry. There were 528 deaths (6.6-year all-cause mortality 41.1%). Survival was greatest in the cTnI ≤ 0.06-µg/L subgroup at 30 days (p = 0.005), 6 months (p = 0.015), 1 year (p = 0.002), and 6.6 years (p = 0.045). After adjustment there was no significant difference in survival between the cTnI >0.06- to < 0.5-µg/L and ≥ 0.5-µg/L subgroups. Increased mortality (hazard ratio, 95% confidence interval) was associated with ages 70 to 80 years (2.58, 1.17 to 3.91) and >80 years (3.30, 3.50 to 5.06), peripheral vascular disease (1.50, 1.16 to 1.94), heart failure (1.36, 1.05 to 1.83), diabetes mellitus (1.68, 1.36 to 2.07), severe left ventricular systolic dysfunction (1.50, 1.00 to 2.21), and creatinine per 10 µmol/L (1.65, 1.02 to 1.08), whereas ages 50 to 60 years (0.55, 0.32 to 0.96), ß blockers (0.53, 0.44 to 0.64), aspirin (0.80 0.65 to 0.99), angiotensin-converting enzyme inhibitors (0.67, 0.56 to 0.80), statins (0.73, 0.59 to 0.90), and revascularization (0.33, 0.12 to 0.92) were associated with a lower risk of death. In conclusion, although quantitative evaluation of cTnI concentration in patients with acute coronary syndrome with cTnI > 0.06 µg/L was associated with no added prognostic information, the dichotomization of patients by cTnI status ("positive" and "negative") facilitates acute coronary syndrome risk stratification.

Discovery and synthesis of a new class of opioid ligand having a 3-azabicyclo[3.1.0]hexane core. An example of a 'magic methyl' giving a 35-fold improvement in binding.

In looking for a novel achiral µ opioid receptor antagonist for the treatment of pruritus, we designed and synthesised azabicyclo[3.1.0]hexane compounds as a new class of opioid ligand. During optimisation, an addition of a single methyl resulted in a 35-fold improvement in binding. An early example from the series had excellent µ opioid receptor antagonist antagonist activity and was very effective in an in vivo pruritus study.

Practical solvent system selection for counter-current separation of pharmaceutical compounds.

Counter-current chromatography (CCC) is a technique that shows a lot of potential for large scale purification. Its usefulness in a "research and development" pharmaceutical environment has been investigated, and the conclusions are shown in this article. The use of CCC requires the development of an appropriate solvent system (a parameter of critical importance), a process which can be tedious. This article presents a novel strategy, combining a statistical approach and fast HPLC to generate a three-dimensional partition coefficient map and rapidly predict an optimal solvent system. This screen is performed in half a day and involves 9 experiments per solvent mixture. Test separations were performed using that screen to ensure the validity of the method.

Organic solvent nanofiltration in asymmetric hydrogenation: enhancement of enantioselectivity and catalyst stability by ionic liquids.

This communication describes the enhancement of the enantioselectivity and the stability of Ru-BINAP with the ionic liquid trihexyl(tetradecyl)phosphonium chloride (CyPhos101), and the use of organic solvent nanofiltration for the efficient separation of the catalyst and ionic liquid from the hydrogenation product, followed by simultaneous recycling of the catalyst and ionic liquid.