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This paper describes our experience with a case study that was intended to provide business students with a straightforward exercise in operational research/management science (OR/MS) but which consistently produces a learning experience for students that is quite different from that envisaged when the case was originally written. An effort is made to explain the surprising results in the classroom. This example demonstrates the fact that building OR/MS models often reveals important dimensions of a problem that otherwise might remain unexplored. The richness of this case also demonstrates the value of exposing OR/MS students to real problems through the use of cases. Keywords: teaching; OR/MS pedagogy; case studies; medical decision analysis

Objectives: In an effort to reduce reimbursement penalty from the Centers for Medicare & Medicaid Services, hospitals have looked to evaluate the effectiveness of existing programs as well as adopt innovative practices to reduce 30-day readmission rates. The objective of this study was to evaluate the impact of delaying prescription fill on 30-day readmission rates for patients with heart failure (HF) and chronic obstructive pulmonary disease (COPD). Identifying an association between delaying prescription fill and readmission rate would validate programs that provide patients with their medications before discharge., Methods: A retrospective chart review was performed for all patients admitted to Henry County Medical Center with an HF or COPD exacerbation from January to October 2016. Outpatient pharmacies were contacted for each patient to determine time of prescription fill. Time of fill was compared with time of discharge, and patients were separated into 2 subgroups: those who filled within 48 hours of discharge and those who filled after 48 hours. The primary outcome was 30-day readmission rate, and a secondary end point was to identify patient characteristics associated with delayed prescription fills., Results: A total of 104 patients were included in the study. COPD patients experienced a lower readmission rate when delaying prescription fill at least 48 hours (P = 0.23). HF patients experienced a higher readmission rate when delaying prescription fill at least 48 hours (P = 0.48). No baseline characteristics were associated with a significantly higher rate of delaying prescription fill., Conclusion: Delaying discharge prescription fills resulted in a nonsignificant increase in the rate of HF readmission but did not increase the rate of readmission for COPD. Rate of delaying prescription fill was not statistically greater for any of the baseline characteristics., (Published by Elsevier Inc.)

Objectives: First, to investigate the prevalence and types of drug therapy problems and medication discrepancies among super-utilizers, and associated patient characteristics. Second, to examine the outcomes of pharmacist recommendations and estimated cost avoidance through care transitions support focused on medication management., Design: Retrospective analysis of the pharmacist-led interventions as part of the SafeMed Program., Setting: A large nonprofit health care system serving the major medically underserved areas in Memphis, Tennessee., Participants: Three hundred seventy-four super-utilizing SafeMed participants with multiple chronic conditions and polypharmacy., Intervention: Comprehensive medication review, medication therapy management, enhanced discharge planning, home visits, telephone follow-up, postdischarge medication reconciliation, and care coordination with physicians., Main Outcome Measures: Types of drug therapy problems, outcomes of pharmacist recommendations, estimated cost avoided, medication discrepancies, and self-reported medication adherence., Results: Prevalence of drug therapy problems and postdischarge medication discrepancies was 80.7% and 75.4%, respectively. The most frequently occurring drug therapy problems were enrollee not receiving needed medications (33.4%), underuse of medications (16.9%), and insufficient dose or duration (11.2%). Overall 50.8% of the pharmacist recommendations were accepted by physicians and patients, resulting in an estimated cost avoidance of $293.30 per drug therapy problem identified. Multivariate analysis indicated that participants with a higher number of comorbidities were more likely to have medication discrepancies (odds ratio 1.23 [95% CI 1.05-1.44]). Additional contributors to postdischarge medication discrepancies were difficulty picking up and paying for medications and not being given necessary prescriptions before discharge., Conclusion: Drug therapy problems and medication discrepancies are common in super-utilizers with multiple chronic conditions and polypharmacy during transitions of care, and greater levels of comorbidity magnify risk. Pharmacist-led interventions in the SafeMed Program have demonstrated success in resolving enrollees' medication-related issues, resulting in substantial estimated cost savings. Preliminary evidence suggests that the SafeMed model's focus on medication management has great potential to improve outcomes while reducing costs for vulnerable super-utilizing populations nationwide., (Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the design, implementation, and early experience of the SafeMed program, which uses certified pharmacy technicians in a novel expanded role as community health workers (CPhT-CHWs) to improve transitions of care., Setting: A large nonprofit health care system serving the major medically underserved areas and geographic hotspots for readmissions in Memphis, TN., Practice Innovation: The SafeMed program is a care transitions program with an emphasis on medication management designed to use low-cost health workers to improve transitions of care from hospital to home for superutilizing patients with multiple chronic conditions and polypharmacy., Evaluation: CPhT-CHWs were given primary responsibility for patient outreach after hospital discharge with the use of home visits and telephone follow-up. SafeMed program CPhT-CHWs served as pharmacist extenders, obtaining medication histories, assisting in medication reconciliation and identification of potential drug therapy problems (DTPs), and reinforcing medication education previously provided by the pharmacist per protocol., Results: CPhT-CHW training included patient communication skills, motivational interviewing, medication history taking, teach-back techniques, drug disposal practices, and basic disease management. Some CPhT-CHWs experienced difficulties adjusting to an expanded scope of practice. Nonetheless, once the Tennessee Board of Pharmacy affirmed that envisioned SafeMed CPhT-CHW roles were consistent with Board rules, additional responsibilities were added for CPhT-CHWs to enhance their effectiveness. Patient outreach teams including CPhT-CHWs achieved increases in home visit and telephone follow-up rates and were successful in helping identify potential DTPs., Conclusion: The early experience of the SafeMed program demonstrates that CPhT-CHWs are well suited for novel expanded roles to improve care transitions for superutilizing populations. CPhT-CHWs can identify and report potential DTPs to the pharmacist to help target medication therapy management. Critical success factors include strong CPhT-CHW patient-centered communication skills and strong pharmacist champions. In collaboration with state pharmacy boards and pharmacist associations, the SafeMed CPhT-CHW model can be successfully scaled to serve superutilizing patients throughout the country., (Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Nonviral gene delivery vectors now show good therapeutic potential: however, detailed characterization of the composition and macromolecular organization of such particles remains a challenge. This paper describes experiments to elucidate the structure of a ternary, targeted, lipopolyplex synthetic vector, the LID complex. This consists of a lipid component, Lipofectin (L) (1:1 DOTMA:DOPE), plasmid DNA (D), and a dual-function, cationic peptide component (I) containing DNA condensation and integrin-targeting sequences. Fluorophore-labeled lipid, peptide, and DNA components were used to formulate the vector, and the stoichiometry of the particles was established by fluorescence correlation spectroscopy (FCS). The size of the complex was measured by FCS, and the sizes of LID, L, LD, and ID complexes were measured by dynamic light scattering (DLS). Fluorescence quenching experiments and freeze-fracture electron microscopy were then used to demonstrate the arrangement of the lipid, peptide, and DNA components within the complex. These experiments showed that the cationic portion of the peptide, I, interacts with the plasmid DNA, resulting in a tightly condensed DNA-peptide inner core; this is surrounded by a disordered lipid layer, from which the integrin-targeting sequence of the peptide partially protrudes.

Human airway epithelial cell targeting peptides were identified by biopanning on 1HAEo-cells, a well characterised epithelial cell line. Bound phage were recovered after three rounds of binding, high stringency washing and elution, leading to the production of an enriched phage peptide population. DNA sequencing of 56 clones revealed 14 unique sequences. Subsequent binding analysis revealed that 13 of these peptides bound 1HAEo-cells with high affinity. Three peptides, SERSMNF, YGLPHKF and PSGAARA were represented at high frequency. Three clearly defined families of peptide were identified on the basis of sequence motifs including (R/K)SM, L(P/Q)HK and PSG(A/T)ARA. Two peptides, LPHKSMP and LQHKSMP contained two motifs. Further detailed sequence analysis by comparison of peptide sequences with the SWISSPROT protein database revealed that some of the peptides closely resembled the cell binding proteins of viral and bacterial pathogens including Herpes Simplex Virus, rotavirus, Mycoplasma pneumoniae and rhinovirus, the latter two being respiratory pathogens, as well as peptide YGLPHKF having similarity to a protein of unknown function from the respiratory pathogen Legionella pneumophila. Peptides were incorporated into gene delivery formulations with the cationic lipid Lipofectin and plasmid DNA and shown to confer a high degree of transfection efficiency and specificity in 1HAEo-cells. Improved transfection efficiency and specificity was also observed in human endothelial cells, fibroblasts and keratinocytes. Therefore, on the basis of clone frequency after biopanning, cell binding affinity, peptide sequence conservation and pathogenic similarity, we have identified 3 novel peptide families and 5 specific peptides that have the potential for gene transfer to respiratory epithelium in vivo as well as providing useful in vitro transfection reagents for primary human cell types of scientific and commercial interest.

The structure of the lipoplex formed from DNA and the sugar-based cationic gemini surfactant 1, which exhibits excellent transfection efficiency, has been investigated in the pH range 8.8-3.0 utilizing small-angle X-ray scattering (SAXS) and cryo-electron microscopy (cryo-TEM). Uniquely, three well-defined morphologies of the lipoplex were observed upon gradual acidification: a lamellar phase, a condensed lamellar phase, and an inverted hexagonal (H(II)) columnar phase. Using molecular modeling, we link the observed lipoplex morphologies and physical behavior to specific structural features in the individual surfactant, illuminating key factors in future surfactant design, viz., a spacer of six methylene groups, the presence of two nitrogens that can be protonated in the physiological pH range, two unsaturated alkyl tails, and hydrophilic sugar headgroups. Assuming that the mechanism of transfection by synthetic cationic surfactants involves endocytosis, we contend that the efficacy of gemini surfactant 1 as a gene delivery vehicle can be explained by the unprecedented observation of a pH-induced formation of the inverted hexagonal phase of the lipoplex in the endosomal pH range. This change in morphology leads to destabilization of the endosome through fusion of the lipoplex with the endosomal wall, resulting in release of DNA into the cytoplasm.

In a study of zinc status in the elderly, the mean serum and leucocyte zinc concentrations were found to be significantly lower in continuing-care patients compared with elderly people living in the community. The mean daily dietary intakes of zinc, protein and fibre did not differ between the two groups. Serum zinc levels were found to correlate with serum albumin levels. No significant relationship was found between the mean serum or leucocyte zinc concentrations of patients and either their mental status or the presence of skin pressure damage, leg ulcers or unhealed wounds.