Children with NC-CDs accounted for 33% of pediatric Medicaid expenditures and have significantly higher PMPY and aggregate annual expenditures than children WO-CDs. The annual aggregate expenditures of the NC-CD group represent a significant societal cost because of the high volume of children, extrapolated to ∼$34.9 billion annually in national Medicaid expenditures.

No abstract

Nonmedical costs place burdens on families of children who are hospitalized, disproportionately affecting those with competing socioeconomic challenges.

The conventional Morita-Baylis-Hillman (MBH) reaction entails condensation of an a,b-unsaturated carbonyl compound with an aldehyde to afford an a-hydroxyalkyl enone. [1] The reaction proceeds by initial conjugate addition between an enone and a nucleophilic promoter (usually a tertiary amine or trialkyl phosphine) to generate a zwitterionic enolate. Addition to an aldehyde electrophile and elimination of the nucleophilic promoter completes the reaction (Scheme 1). The products of MBH reactions are useful synthetic intermediates and building blocks; hence, considerable effort has been directed toward determining the mechanistic details of this transformation.[2] Variations of MBH reactions have been reported in which reactive enolates are prepared from enones in the presence of transition-metal or Lewis acid reagents.[1a] The range of electrophilic reaction partners also has been expanded to include activated ketones, other enones, [3] allylic electrophiles (including p-allyl-palladium complexes), [4,5] alkyl halides, [6] epoxides, [7] and aryl bismuth reagents. [8] Despite these noteworthy advances, the MBH reaction remains limited in scope owing to the reluctant participation of nonactivated and/or substituted a,b-unsaturated carbonyl compounds. Acrylamides especially have proven to be particularly difficult substrates, and only a few examples of MBH reactions between simple acrylamides and activated aldehydes have been reported. [9] In contrast to this generally observed reactivity profile, we have found that N-benzyl acrylamides metalated with a {CpRu II } fragment (Cp = cyclopentadienyl) readily undergo intramolecular MBH cyclizations in the presence of added nucleophile and base (Scheme 2). The ruthenium-arene fragment serves as the electrophilic reaction partner in these transformations, resulting in formation of ruthenium-cyclohexadienyl complexes as the initial products. Subsequent demetalation then delivers highly functionalized spirolactams. These transformations represent the first examples of direct metal-arene participation in MBH-type reactions. [10] We first became interested in exploring the feasibility of the reaction sequence shown in Scheme 2 after discovering that both N-benzyl acetoacetamides (1) and N-benzyl-bamidophosphonates (2) can be converted to 2-azaspirocyclic cyclohexadienyl complexes by an initial nucleophilic aromatic addition followed by enolate trapping and olefination, respectively. [11,12] Generation of a reactive enolate by means of an MBH-type reaction of a coordinated acrylamide, however, offers a more direct and potentially more versatile entry into the azaspiro[4.5]decane framework. Initial attempts to effect the conversion of the simple (N-benzyl acrylamide)-ruthenium complex 3 to the corresponding spirocyclic derivative under MBH conditions seemingly confirmed the sluggish reactivity of unsaturated amide substrates. After considerable experimentation, however, we were pleased to find that the reaction conditions shown in Equation (1) delivered the desired produc...

BACKGROUND AND OBJECTIVES: Expenditures for children with noncomplex chronic diseases (NC-CDs) are related to disease chronicity and resource use. The degree to which specific conditions contribute to high health care expenditures among children with NC-CDs is unknown. We sought to describe patient characteristics, expenditures, and use patterns of children with NC-CDs with the lowest (≤80th percentile), moderate (81-95th percentile), high (96-99th percentile), and the highest (≥99th percentile) expenditures. METHODS: In this retrospective cross-sectional study, we used the 2014 Truven Medicaid MarketScan Database for claims from 11 states. We included continuously enrolled children (age <18 years) with NC-CDs (n = 1 563 233). We describe per member per year (PMPY) spending and use by each expenditure group for inpatient services, outpatient services, and the pharmacy for physical and mental health conditions. K-means clustering was used to identify expenditure types for the highest expenditure group.

No abstract

Each quality improvement (QI) project has an implicit study design, although these designs are not discussed as commonly as they are in clinical research. Most QI projects fall under the quasi-experimental study category, in which observations are made before and after the implementation of an intervention(s). The simplest and most commonly used for QI studies is the pre-post design, in which observations are made before and after each intervention that was implemented over a specified period. More sophisticated designs for QI studies enable a study team to draw stronger inferences about the system that is being changed and the individual effects of the interventions that are implemented. In the final commentary in this QI series, we discuss these study designs and focus on the strengths and weaknesses of more sophisticated designs, including cluster randomized, stepped-wedge, and factorial designs.

The conventional Morita-Baylis-Hillman (MBH) reaction entails condensation of an a,b-unsaturated carbonyl compound with an aldehyde to afford an a-hydroxyalkyl enone. [1] The reaction proceeds by initial conjugate addition between an enone and a nucleophilic promoter (usually a tertiary amine or trialkyl phosphine) to generate a zwitterionic enolate. Addition to an aldehyde electrophile and elimination of the nucleophilic promoter completes the reaction (Scheme 1). The products of MBH reactions are useful synthetic intermediates and building blocks; hence, considerable effort has been directed toward determining the mechanistic details of this transformation.[2] Variations of MBH reactions have been reported in which reactive enolates are prepared from enones in the presence of transition-metal or Lewis acid reagents.[1a] The range of electrophilic reaction partners also has been expanded to include activated ketones, other enones, [3] allylic electrophiles (including p-allyl-palladium complexes), [4,5] alkyl halides, [6] epoxides, [7] and aryl bismuth reagents. [8] Despite these noteworthy advances, the MBH reaction remains limited in scope owing to the reluctant participation of nonactivated and/or substituted a,b-unsaturated carbonyl compounds. Acrylamides especially have proven to be particularly difficult substrates, and only a few examples of MBH reactions between simple acrylamides and activated aldehydes have been reported. [9] In contrast to this generally observed reactivity profile, we have found that N-benzyl acrylamides metalated with a {CpRu II } fragment (Cp = cyclopentadienyl) readily undergo intramolecular MBH cyclizations in the presence of added nucleophile and base (Scheme 2). The ruthenium-arene fragment serves as the electrophilic reaction partner in these transformations, resulting in formation of ruthenium-cyclohexadienyl complexes as the initial products. Subsequent demetalation then delivers highly functionalized spirolactams. These transformations represent the first examples of direct metal-arene participation in MBH-type reactions. [10] We first became interested in exploring the feasibility of the reaction sequence shown in Scheme 2 after discovering that both N-benzyl acetoacetamides (1) and N-benzyl-bamidophosphonates (2) can be converted to 2-azaspirocyclic cyclohexadienyl complexes by an initial nucleophilic aromatic addition followed by enolate trapping and olefination, respectively. [11,12] Generation of a reactive enolate by means of an MBH-type reaction of a coordinated acrylamide, however, offers a more direct and potentially more versatile entry into the azaspiro[4.5]decane framework. Initial attempts to effect the conversion of the simple (N-benzyl acrylamide)-ruthenium complex 3 to the corresponding spirocyclic derivative under MBH conditions seemingly confirmed the sluggish reactivity of unsaturated amide substrates. After considerable experimentation, however, we were pleased to find that the reaction conditions shown in Equation (1) delivered the desired produc...