Determining the cost-effectiveness of follitropin alfa biosimilar compared to follitropin alfa originator in women undergoing fertility treatment in France.

Objective: The study assessed cost-effectiveness of follitropin alfa biosimilar versus the originator in terms of cost per cumulative live-birth (CLB) for the French healthcare system based on real-world evidence. Follitropin alfa biosimilars have been shown to have comparable clinical outcomes to the originator, in both clinical studies and real-world settings, in terms of oocyte retrieval and cumulative live-birth rate (CLBR). Previous health economic studies comparing the cost-effectiveness of follitropin alfa biosimilars against the originator utilised clinical trial data, leaving ambiguity over cost-effectiveness in real-world settings. Additionally, previous cost-effectiveness analysis has been performed for live-births following only fresh embryo transfers, whereas, fresh and frozen transfers are common in clinical practice. This study investigates the cost per CLB, which more closely models clinical practice. Study design: A decision-tree cost-effectiveness model was developed based on the total costs and CLBR per ovarian stimulation (OS) for a follitropin alfa biosimilar (Bemfola®, Gedeon Richter Plc, Budapest, Hungary) and the originator (Gonal-f®, Merck KGaA, Darmstadt, Germany). A time horizon of one year from oocyte retrieval to embryo transfer was used but costs from resulting transfers were also included. Clinical inputs were taken from the REOLA real-world study or clinician insights, while acquisition costs were taken from French public databases. The output was cost per CLB following one OS. One-way sensitivity analysis was performed to determine the largest model drivers. Results: Cost per CLB was €18,147 with follitropin alfa biosimilar and €18,834 with the originator, saving €687 per CLB following OS with the biosimilar. When wastage estimates were considered the biosimilar cost saving is estimated to be between €796 and €1155 per CLB further increasing cost savings. Irrespective of wastage, if used ubiquitously throughout France for ART, the biosimilar could save the French health system €13,994,190 or lead to 771 more births when compared to its higher-cost originator. Sensitivity analysis showed that the originator's relative CLBR had the greatest impact on the model. Conclusion: This analysis demonstrates that the follitropin alfa biosimilar, Bemfola®, is a more cost-effective option for OS compared with the originator from a French healthcare payer perspective, in terms of cost per CLB.

A real-world study of ART in France (REOLA) comparing a biosimilar rFSH against the originator according to rFSH starting dose.

BACKGROUND: Since the first launch of a biosimilar recombinant follicle stimulating hormone (rFSH), Bemfola®, in Europe in 2014, it has been possible to study in routine clinical care throughout France the effectiveness of a biosimilar rFSH including according to different rFSH starting doses. METHODS: REOLA was a non-interventional, retrospective, real world study using anonymized data from 17 Assisted Reproductive Technology (ART) centres' data management systems across France including 2,319 ART ovarian stimulation cycles with Bemfola® and 4,287 ART ovarian stimulation cycles with Gonal-f®. For both products, four populations were studied according to starting dose of rFSH: < 150 IU, 150 - 224 IU, 225 - 299 IU and ≥ 300 IU. The primary endpoint was the cumulative live birth rate (cLBR) per commenced ART ovarian stimulation cycle including all subsequent fresh and frozen-thawed embryo transfers starting during a follow up period of at least 1 year following oocyte retrieval. RESULTS: A direct relationship of increasing rFSH starting dose with increasing age, increasing basal FSH, decreasing AMH and increasing body mass index was noted. No clinically relevant differences were seen in all outcomes reported, including the cLBR, between Bemfola® and Gonal-f®, but for both drugs, an association was seen with increasing rFSH starting dose and decreasing cLBR. CONCLUSIONS: The REOLA study demonstrates that the cLBR with Bemfola® is very similar to Gonal-f® across all patient subpopulations. The cLBR is inversely related to the rFSH starting dose irrespective of the drug used, and the REOLA study provides reassurance of the clinical effectiveness of a biosimilar rFSH used in a real world setting.

Qualitative risk assessment of follicle stimulating hormone injectable products.

BACKGROUND: Gonadotropin injections for fertility treatment regimens are usually self-injected, typically over 8-12 days during the assisted reproductive technology cycle. Parenteral gonadotropins are available in different formulations and administered through various systems. A user experience study and risk assessment were performed to evaluate different product types for risks to the patient when preparing and administering injections. METHODS: Nine women of child-bearing age each prepared and administered injections of six products representing single- and multidose vials of menotropin for reconstitution (Merional® and Menopur®), follicle stimulating hormone (FSH) reusable pen injectors with (Puregon®), and without cartridges (Gonal-f®), and single-use FSH pre-filled pens (Bemfola®). Risk assessments based on user feedback were made with reference to EU regulations for implementing practices for safe use of injectable products. RESULTS: Products requiring reconstitution with diluent in glass ampoules were associated with medium risk for sharps injury and a lower level of user confidence. Pen injectors were considered easy-to-use, with a low risk of sharps injury. Single-use pens were associated with the lowest risk of dosing errors. CONCLUSIONS: The study identifies differences in the risks for both sharps injuries and dosing errors between FSH delivery options that practitioners should consider when making a treatment choice.

The continuum of ovarian response leading to BIRTH, a real world study of ART in Spain.

BACKGROUND: The first biosimilar of recombinant follicle stimulating hormone (rFSH) launched in Europe was Bemfola® in 2014 following a clinical development programme demonstrating efficacy and safety to the satisfaction of the European Medicines Agency. Since then the increasing use of biosimilar rFSH has provided the opportunity to study both effectiveness across the whole population and the variation of rFSH use during routine clinical care in a real-world setting in Spain. METHODS: This is a real-world study of 1222 women treated in 26 assisted reproduction treatment centres throughout Spain providing experience of the use of a biosimilar recombinant follicle stimulating hormone in four distinct populations. The four populations studied were poor responders, suboptimal responders, normal responders and oocyte donors. The primary endpoint was the total number of oocytes retrieved. Secondary endpoints included number of days of rFSH stimulation, total dose of rFSH administered, number of MII oocytes, number of fertilized oocytes, quality of embryos, number of embryos transferred, implantation rates, clinical pregnancy rates following embryo transfer, number of multiple pregnancies and number of serious adverse reactions, including moderate-to-severe OHSS. RESULTS: Differences were seen across the populations both in the characteristics of the women and ART outcomes suggestive of a continuum of fertility prognosis. In the poor responders, suboptimal responders, normal responders and oocyte donor populations the mean age in years was 39.9 (±SD 3.4), 38.4 (±SD 2.9), 34.4 (±SD 3.3) and 26 (±SD 4.6) respectively and number of oocytes retrieved was 4.1 (±SD 2.7), 8.6 (±SD 6.0), 12.2 (±SD 7.2) and 19.5 (±SD 9.5) respectively. The proportion of embryos graded as best quality was 18.5%, 33.0% and 43.8%, and graded as worst quality was 20.4%, 5.8% and 5.8% for poor responders, suboptimal responders and normal responders respectively. In a similar pattern, for poor responders, suboptimal responders and normal responders the implantation rates were 16.0%, (8/50), 22.4% (49/219), 30.6% (97/317) respectively and clinical pregnancy rates were 23.2% (10/43), 30.4% (59/194) and 37.0% (114/308) respectively. Adverse events were reported in only 7 of 1222 women (0.6%). CONCLUSIONS: Overall the results were consistent with the national ART results reported for Spain, hence this study provides reassurance of the clinical effectiveness of a biosimilar rFSH used in a real world setting. TRIAL REGISTRATION: ClinicalTrials.gov identifier - NCT02941341.

Empathetic application of machine learning may address appropriate utilization of ART.

The value of artificial intelligence to benefit infertile patients is a subject of debate. This paper presents the experience of one aspect of artificial intelligence, machine learning, coupled with patient empathy to improve utilization of assisted reproductive technology (ART), which is an important aspect of care that is under-recognized. Although ART provides very effective options for infertile patients to build families, patients often discontinue ART when further treatment is likely to be beneficial and most of these patients do not achieve pregnancy without medical aid. Use of ART is only in part dependent on financial considerations; stress and other factors play a major role, as shown by high discontinuation rates despite reimbursement. This commentary discusses challenges and strategies to providing personalized ART prognostics based on machine learning, and presents a case study where appropriate use of such prognostics in ART centres is associated with a trend towards increased ART utilization.

Bemfola® fixed dose pens potentially reduce drug wastage and associated costs of infertility treatment.

Bemfola® is a recombinant follicle-stimulating hormone (FSH) used during infertility treatment. One main differentiator between FSH products is their delivery device; consisting of multi-dose pens (Gonal-f®), vials or multi-dose preparations (Menopur®), or adjustable daily disposable dose pens (Bemfola®). To determine the potential impact of delivery device on drug wastage during infertility treatment this study retrospectively analysed Gonal-f® and Menopur® prescription and usage data from five UK clinics. Incurred drug wastage was then compared to potential Bemfola® drug wastage. Data collected included: (i) number of treatment cycles; (ii) daily FSH dose; (iii) length of treatment; (iv) dose adjustment following ultrasound scan; (v) FSH formulation(s) prescribed and (vi) agonist/antagonist protocol used. Treatment with Gonal-f® (4078 cycles) and Menopur® (646 cycles) resulted in an average drug wastage of 160 and 294 IU per treatment cycle. Use of Bemfola® instead of Gonal-f® and Menopur® may reduce the wastage to 104 and 61 IU per cycle, respectively. The use of Bemfola®, across all 4724 cycles, could result in a drug wastage reduction of up to 376,800 IUs with an associated cost saving of £100,011. Bemfola® is a viable alternative to Gonal-f® and Menopur® with its drug delivery system potentially reducing drug wastage and associated costs during infertility treatment.

An evaluation by potential IVF/Donor Oocyte patients of the Use and Handling of the Bemfola® Pen compared with the Gonal-f® Pen and Puregon Pen® / Evaluación del uso y manejo de la pluma Bemfola® en comparación con el de la pluma Gonal-f® y la pluma Puregon® en pacientes potenciales de FIV/ donantes de ovocitos

BACKGROUND: Since the 1990s recombinant human FSH (r-hFSH), such as Gonal-f® and Puregon®, have been in widespread use for fertility treatment [1]. More recently Bemfola®, biosimilar to r-hFSH, has been introduced with similar efficacy and safety to Gonal-f® [2], but delivered in a novel, innovative injector pen system (Reddot design award 2011). The Bemfola® pen (BP) is a single-use, disposable pen available in five different presentations (i.e., 75IU, 150IU, 225IU, 300IU and 450IU), each of which provides a range of doses that it can deliver. Non-compliance to hormonal treatment regimens might be a critical issue to reach therapeutic goals. The use of pens by patients is often limited by factors such as fear of injection, but can be also related to the device itself [3-6]. Therefore, easy-to-use devices may also positively influence physicians» hormonal prescribing habits and patient's compliance. Accordingly, this user acceptance study aimed to assess the use of the Bemfola® pen in a population of potential users with regard to the easiness and convenience of handling of the Bemfola® Pen in comparison to the Gonal-f® pen and Puregon® pen. Material and Methods Randomised and single-blind study with three-arm user test. The investigation was conducted in females who considered undergoing hormonal treatment for the first time (naïve) and who were considering to start an IVF or donor egg treatment cycle. A total of 10 centers from Spain participated in this investigation. This study of user acceptance included 460 females qualifying for potential patients considering a therapy with follicle stimulating hormone. Users received the three pens in a randomized, consecutive sequence, completed for each of the pen one questionnaire (same for all 3 pens) and thereafter completed a concluding questionnaire comparing the handling, convenience and indicating their preference among the 3 pens. No self-injections were performed and an application pad for injections was used. Results The Bemfola® pen showed the highest scorings and strong preferences in all pen features assessed and achieved the highest proportion of best choice compared to both the Gonal-f® and Puregon®. pen. Conclusions The results indicated significant preferences of women, who intended to undergo a hormonal treatment, for the Bemfola® pen compared to both the Puregon® pen and the Gonal-f® pen

ANTECEDENTES: Desde la década de los noventa, la hormona foliculoestimulante humana recombinante (hFSH-r) como Gonal-f® y Puregon®, se ha utilizado ampliamente en el tratamiento de la fertilidad [1]. Más recientemente se ha introducido Bemfola®, biosimilar de la hFSH-r con eficacia y seguridad similar a Gonal-f® [2], pero desarrollada con un innovador sistema de pluma inyectora (premio de diseño Reddot, 2011). Bemfola® es una pluma precargada desechable de un solo uso, disponible en cinco presentaciones diferentes (75 UI, 150 UI, 225 UI, 300 UI y 450 UI), cada una de las cuales proporciona un rango de dosis determinado. El no-cumplimiento de las pautas de tratamiento hormonal es un problema fundamental en la consecución de los objetivos terapéuticos. El uso de plumas por las pacientes se ve a menudo limitado por el miedo a la inyección e incluso relacionado con el propio dispositivo [3-6]. Por tanto, los dispositivos de fácil uso pueden influir positivamente tanto en los hábitos de prescripción de terapias hormonales de los médicos como en el cumplimiento del paciente. En consecuencia, el objetivo de este estudio consiste en evaluar el uso de Bemfola® en una población de usuarias potenciales con respecto a la facilidad, y conveniencia en su manejo en comparación con las plumas Gonal-f® y Puregon®. Material y Métodos Estudio aleatorizado y simple ciego de tres ramas de tratamiento. Esta investigación se llevó a cabo en mujeres sin tratamiento previo que estaban considerando bien iniciar un ciclo de FIV o bien ser donantes de ovocitos. En este estudio participaron 10 centros de fertilidad de España. Se incluyeron 460 mujeres cualificadas para ser «pacientes potenciales de terapia hormonal con hormona foliculoestimulante humana recombinante» Las usuarias recibieron las tres plumas (Bemfola®, Gonal-f® y Puregon®) en una secuencia aleatoria y consecutiva, y completaron un cuestionario idéntico por cada una de las plumas, y un cuestionario de conclusión con el fin de comparar el manejo, la comodidad y la preferencia de las tres plumas. En ningún caso se realizaron auto-inyecciones y en su lugar se utilizó una almohadilla de aplicación de inyecciones. Resultados La pluma Bemfola® mostró la mayor puntuación y elevadas preferencias en todas las características evaluadas, y alcanzó la mayor proporción de «mejor» opción en comparación con la pluma Gonal-f® y la pluma Puregon®. Conclusiones Los resultados mostraron preferencias significativas de mujeres que tenían la intención de someterse a un tratamiento hormonal, para la pluma Bemfola® en comparación con las plumas Gonal-f® y Puregon®

Evaluación del uso y manejo de la pluma Bemfola® en comparación con el de la pluma Gonal-f® y la pluma Puregon® en pacientes potenciales de FIV/ donantes de ovocitos / An evaluation by potential IVF/Donor Oocyte patients of the Use and Handling of the Bemfola® Pen compared with the Gonal-f® Pen and Puregon Pen®

ANTECEDENTES: Desde la década de los noventa, la hormona foliculoestimulante humana recombinante (hFSH-r) como Gonal-f® y Puregon®, se ha utilizado ampliamente en el tratamiento de la fertilidad [1]. Más recientemente se ha introducido Bemfola®, biosimilar de la hFSH-r con eficacia y seguridad similar a Gonal-f® [2], pero desarrollada con un innovador sistema de pluma inyectora (premio de diseño Reddot, 2011). Bemfola® es una pluma precargada desechable de un solo uso, disponible en cinco presentaciones diferentes (75 UI, 150 UI, 225 UI, 300 UI y 450 UI), cada una de las cuales proporciona un rango de dosis determinado. El no-cumplimiento de las pautas de tratamiento hormonal es un problema fundamental en la consecución de los objetivos terapéuticos. El uso de plumas por las pacientes se ve a menudo limitado por el miedo a la inyección e incluso relacionado con el propio dispositivo [3-6]. Por tanto, los dispositivos de fácil uso pueden influir positivamente tanto en los hábitos de prescripción de terapias hormonales de los médicos como en el cumplimiento del paciente. En consecuencia, el objetivo de este estudio consiste en evaluar el uso de Bemfola® en una población de usuarias potenciales con respecto a la facilidad, y conveniencia en su manejo en comparación con las plumas Gonal-f® y Puregon®. Material y MÉTODOS: Estudio aleatorizado y simple ciego de tres ramas de tratamiento. Esta investigación se llevó a cabo en mujeres sin tratamiento previo que estaban considerando bien iniciar un ciclo de FIV o bien ser donantes de ovocitos. En este estudio participaron 10 centros de fertilidad de España. Se incluyeron 460 mujeres cualificadas para ser «pacientes potenciales de terapia hormonal con hormona foliculoestimulante humana recombinante». Las usuarias recibieron las tres plumas (Bemfola®, Gonal-f® y Puregon®) en una secuencia aleatoria y consecutiva, y completaron un cuestionario idéntico por cada una de las plumas, y un cuestionario de conclusión con el fin de comparar el manejo, la comodidad y la preferencia de las tres plumas. En ningún caso se realizaron auto-inyecciones y en su lugar se utilizó una almohadilla de aplicación de inyecciones. RESULTADOS: La pluma Bemfola® mostró la mayor puntuación y elevadas preferencias en todas las características evaluadas, y alcanzó la mayor proporción de «mejor» opción en comparación con la pluma Gonal-f® y la pluma Puregon®. CONCLUSIONES: Los resultados mostraron preferencias significativas de mujeres que tenían la intención de someterse a un tratamiento hormonal, para la pluma Bemfola® en comparación con las plumas Gonal-f® y Puregon®

BACKGROUND: Since the 1990s recombinant human FSH (r-hFSH), such as Gonal-f® and Puregon®, have been in widespread use for fertility treatment [1]. More recently Bemfola® has been introduced with familiar efficacy and safety to Gonal-f® [2], but delivered in a novel, innovative injector pen system (Reddot design award 2011). The Bemfola® pen (BP) is a singleuse, disposable pen available in five different presentations (i.e., 75IU, 150IU, 225IU, 300IU and 450IU), each of which provides a range of doses that it can deliver. Non-compliance to hormonal treatment regimens might be a critical issue to reach therapeutic goals. The use of pens by patients is often limited by factors such as fear of injection, but can be also related to the device itself [3-6]. Therefore, easy-to-use devices may also positively influence physicians' hormonal prescribing habits and patient's compliance. Accordingly, this user acceptance study aimed to assess the use of the Bemfola® pen in a population of potential users with regard to the easiness and convenience of handling of the Bemfola® Pen in comparison to the Gonal-f® pen and Puregon® pen. Material and methods Randomised and single-blind study with three-arm user test. The investigation was conducted in females who considered undergoing hormonal treatment for the first time (naïve) and who were considering to start an IVF or donor egg treatment cycle. A total of two 10 centres from Spain participated in this investigation. This study of user acceptance included 460 females qualifying for potential patients considering a therapy with follicle stimulating hormone. Users received the three pens in a randomized, consecutive sequence, complete for each of the pen one questionnaire (same for all 3 pens) and thereafter complete a concluding questionnaire comparing the handling, convenience and indicating their preference among the 3 pens. No self-injections were performed and an application pad for injections was used. Results The Bemfola® pen showed the highest scorings and strong preferences in all pen features assessed and achieved the highest proportion of best choice compared to both, the Gonal-f® and Puregon® pen. Conclusions The results indicated significant preferences of women, who intended to undergo a hormonal treatment, for the Bemfola® pen compared to both the Puregon® pen and the Gonal-f® pen

Auditory Evoked M100 Response Latency is Delayed in Children with 16p11.2 Deletion but not 16p11.2 Duplication.

Individuals with the 16p11.2 BP4-BP5 copy number variant (CNV) exhibit a range of behavioral phenotypes that may include mild impairment in cognition and clinical diagnoses of autism spectrum disorder (ASD). To better understand auditory processing impairments in populations with this chromosomal variation, auditory evoked responses were examined in children with the 16p11.2 deletion, 16p11.2 duplication, and age-matched controls. Stimuli consisted of sinusoidal binaural tones presented passively while children underwent recording with magnetoencephalography (MEG). The primary indicator of auditory processing impairment was the latency of the ∼100-ms "M100" auditory response detected by MEG, with the 16p11.2 deletion population exhibiting profoundly delayed M100 latencies relative to controls. This delay remained even after controlling for potential confounds such as age and cognitive ability. No significant difference in M100 latency was observed between 16p11.2 duplication carriers and controls. Additionally, children meeting diagnostic criteria for ASD (16p11.2 deletion carriers) exhibited nonsignificant latency delays when compared with the corresponding CNV carriers not meeting criteria for ASD. Present results indicate that 16p11.2 deletion is associated with auditory processing delays analogous to (but substantially more pronounced than) those previously reported in "idiopathic" ASD.

Missing and delayed auditory responses in young and older children with autism spectrum disorders.

BACKGROUND: The development of left and right superior temporal gyrus (STG) 50 ms (M50) and 100 ms (M100) auditory responses in typically developing (TD) children and in children with autism spectrum disorder (ASD) was examined. Reflecting differential development of primary/secondary auditory areas and supporting previous studies, it was hypothesized that whereas left and right M50 STG responses would be observed equally often in younger and older children, left and right M100 STG responses would more often be absent in younger than older children. In ASD, delayed neurodevelopment would be indicated via the observation of a greater proportion of ASD than TD subjects showing missing M100 but not M50 responses in both age groups. Missing M100 responses would be observed primarily in children with ASD with language impairment (ASD + LI) (and perhaps concomitantly lower general cognitive abilities). METHODS: Thirty-five TD controls, 63 ASD without language impairment (ASD - LI), and 38 ASD + LI were recruited. Binaural tones were presented. The presence or absence of a STG M50 and M100 was scored. Subjects were grouped into younger (6-10 years old) and older groups (11-15 years old). RESULTS: Although M50 responses were observed equally often in older and younger subjects and equally often in TD and ASD, left and right M50 responses were delayed in ASD - LI and ASD + LI. Group comparisons showed that in younger subjects M100 responses were observed more often in TD than ASD + LI (90 versus 66%, p = 0.04), with no differences between TD and ASD - LI (90 versus 76%, p = 0.14) or between ASD - LI and ASD + LI (76 versus 66%, p = 0.53). In older subjects, whereas no differences were observed between TD and ASD + LI, responses were observed more often in ASD - LI than ASD + LI. Findings were similar when splitting the ASD group into lower- and higher-cognitive functioning groups. CONCLUSION: Although present in all groups, M50 responses were delayed in ASD. Examining the TD data, findings indicated that by 11 years, a right M100 should be observed in 100% of subjects and a left M100 in 80% of subjects. Thus, by 11 years, lack of a left and especially right M100 offers neurobiological insight into sensory processing that may underlie language or cognitive impairment.

The elicitation of audiovisual steady-state responses: multi-sensory signal congruity and phase effects.

Most ecologically natural sensory inputs are not limited to a single modality. While it is possible to use real ecological materials as experimental stimuli to investigate the neural basis of multi-sensory experience, parametric control of such tokens is limited. By using artificial bimodal stimuli composed of approximations to ecological signals, we aim to observe the interactions between putatively relevant stimulus attributes. Here we use MEG as an electrophysiological tool and employ as a measure the steady-state response (SSR), an experimental paradigm typically applied to unimodal signals. In this experiment we quantify the responses to a bimodal audio-visual signal with different degrees of temporal (phase) congruity, focusing on stimulus properties critical to audiovisual speech. An amplitude modulated auditory signal ('pseudo-speech') is paired with a radius-modulated ellipse ('pseudo-mouth'), with the envelope of low-frequency modulations occurring in phase or at offset phase values across modalities. We observe (i) that it is possible to elicit an SSR to bimodal signals; (ii) that bimodal signals exhibit greater response power than unimodal signals; and (iii) that the SSR power at specific harmonics and sensors differentially reflects the congruity between signal components. Importantly, we argue that effects found at the modulation frequency and second harmonic reflect differential aspects of neural coding of multisensory signals. The experimental paradigm facilitates a quantitative characterization of properties of multi-sensory speech and other bimodal computations.

Clinical pharmacokinetics, platelet response, and safety of eltrombopag at supratherapeutic doses of up to 200 mg once daily in healthy volunteers.

This was a double-blind, placebo-controlled, randomized, parallel, dose-escalation study to assess the pharmacokinetics, platelet response, safety, and tolerability of supratherapeutic doses of eltrombopag (100 mg, 150 mg, and 200 mg once daily) administered for 5 days to 33 healthy adult volunteers. Plasma eltrombopag concentrations accumulated between days 1 and 5, with average increases of 66% to 81% for area under the plasma concentration-time curve from time zero to the end of the 24-hour dosing interval (AUC(0-τ)) and 32% to 45% for maximum observed plasma concentration (C(max)) across doses. After 5 days of dosing, AUC(0-τ) was dose-proportional and C(max) was less than dose-proportional over eltrombopag 100 to 200 mg with slope estimates (90% confidence intervals) of 0.92 (0.45-1.39) and 0.76 (0.29-1.22), respectively. Platelet counts peaked at day 14, and maximum change from baseline platelet count increased dose-dependently, with mean platelet count increases of 14, 67, 107, and 150 Gi/L for placebo and eltrombopag 100 mg, 150 mg, and 200 mg, respectively. There was no notable difference in day 14 mean platelet aggregation between eltrombopag (59 to 74%) and placebo (67%), although this was not tested statistically. There was no notable difference in adverse event frequency across eltrombopag doses. Eltrombopag pharmacokinetics and platelet response were dose-dependent, and doses up to 200 mg/d were well tolerated, with safety profiles similar to placebo.

The source and implications of progesterone rise during the follicular phase of assisted reproduction cycles.

Moderate elevations in serum progesterone concentrations are observed following the use of gonadotrophin-releasing hormone agonists during ovarian stimulation. The clinical significance of this phenomenon has been investigated, but findings have been inconclusive. This commentary proposes that progesterone concentrations are indeed important in endometrial advancement and oocyte/embryo development, which, may lead to asynchrony between endometrial and embryo development. Based on the two-cell, two-gonadotrophin model, this commentary proposes a hypothesis to describe how progesterone concentration increases during ovarian stimulation and three factors influencing this during ovarian stimulation are identified: the number of follicles, the FSH drive and the LH activity. It also suggests how differences in gonadotrophin preparations used for ovarian stimulation may have differential effects on progesterone synthesis. It remains to be tested whether routine measurement of late follicular progesterone concentrations may prove beneficial as suitable assay methods are now available. However, strategies that reduce follicular recruitment in high-responding women and gonadotrophins that contain LH activity may reduce the degree of progesterone elevation prior to luteinization.

Eltrombopag does not affect cardiac repolarization: results from a definitive QTc study in healthy subjects.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Some non-anti-arrhythmic drugs delay cardiac repolarization, which can be measured as an increase in the QT interval. Delays in cardiac repolarization create an electrophysiological environment that favours the development of cardiac arrhythmias, which may lead to torsade de pointes, which can be fatal. As part of the clinical development of eltrombopag, a thorough QT(c) study was conducted to evaluate the effects of eltrombopag on cardiac repolarization at both therapeutic and supratherapeutic doses and to characterize the relationship between plasma eltrombopag concentrations and change in QT(c). WHAT THIS STUDY ADDS: This study found no clinically significant QT prolongation for eltrombopag when administered as 50 mg or 150 mg every day for 5 days. There were no safety or tolerability signals of clinical concern. A small incidence of ventricular premature beats was observed, but this was consistent with previously reported incidences in healthy volunteers without apparent heart disease. AIM: To evaluate the effect of eltrombopag on cardiac repolarization and to characterize the relationship between plasma eltrombopag concentrations and change in QT(c). METHODS: This was a double-blind, placebo- and active-controlled, randomized, balanced four-period, crossover study in healthy men and women. Subjects were randomized to receive eltrombopag 50 mg and 150 mg, moxifloxacin 400 mg (positive control) and placebo in one of four sequences. RESULTS: Eighty-seven subjects entered the study and 48 completed. There was no prolongation of QT(c) (Fridericia) following eltrombopag treatment, as the upper limit of the 90% confidence interval (CI) for the time-matched change from baseline in QT(c)F between drug and placebo (ddQT(c)F) did not exceed 10 ms for eltrombopag at either dose. Maximum observed mean treatment difference was 2.29 ms (90% CI 0.34, 4.24) for eltrombopag 150 mg at 1 h post-dose and 11.64 ms (90% CI 9.64, 13.64) for moxifloxacin 400 mg at 4 h. Eltrombopag C(max) and AUC(0,24 h) increased in a dose proportional manner between 50 mg and 150 mg after 5 days' dosing. Proportions of subjects with adverse events were similar across treatments (52-66% of subjects). Most withdrawals (26/39 subjects) were due to elevated platelets. Three subjects were withdrawn for ventricular premature beats (one following each active treatment) reported as related to the study drug. CONCLUSIONS: No clinically significant QT(c) prolongation was observed for eltrombopag at therapeutic and supratherapeutic doses.

The analysis of simple and complex auditory signals in human auditory cortex: magnetoencephalographic evidence from M100 modulation.

OBJECTIVE: Ecologically valid signals (e.g., vowels) have multiple components of substantially different frequencies and amplitudes that may not be equally cortically represented. In this study, we investigate a relatively simple signal at an intermediate level of complexity, two-frequency composite tones, a stimulus lying between simple sinusoids and ecologically valid signals such as speech. We aim to characterize the cortical response properties to better understand how complex signals may be represented in auditory cortex. DESIGN: Using magnetoencephalography, we assessed the sensitivity of the M100/N100m auditory-evoked component to manipulations of the power ratio of the individual frequency components of the two-frequency complexes. Fourteen right-handed subjects with normal hearing were scanned while passively listening to 10 complex and 12 simple signals. The complex signals were composed of one higher frequency and one lower frequency sinusoid; the lower frequency sinusoidal component was at one of the five loudness levels relative to the higher frequency one: -20, -10, 0, +10, +20 dB. The simple signals comprised all the complex signal components presented in isolation. RESULTS: The data replicate and extend several previous findings: (1) the systematic dependence of the M100 latency on signal intensity and (2) the dependence of the M100 latency on signal frequency, with lower frequency signals ( approximately 100 Hz) exhibiting longer latencies than higher frequency signals ( approximately 1000 Hz) even at matched loudness levels. (3) Importantly, we observe that, relative to simple signals, complex signals show increased response amplitude-as one might predict-but decreased M100 latencies. CONCLUSION: : The data suggest that by the time the M100 is generated in auditory cortex ( approximately 70 to 80 msecs after stimulus onset), integrative processing across frequency channels has taken place which is observable in the M100 modulation. In light of these data models that attribute more time and processing resources to a complex stimulus merit reevaluation, in that our data show that acoustically more complex signals are associated with robust temporal facilitation, across frequencies and signal amplitude level.

Eltrombopag, an oral thrombopoietin receptor agonist, has no impact on the pharmacokinetic profile of probe drugs for cytochrome P450 isoenzymes CYP3A4, CYP1A2, CYP2C9 and CYP2C19 in healthy men: a cocktail analysis.

PURPOSE: It is likely that the thrombopoietin receptor agonist eltrombopag will be administered concomitantly with other medications in the treatment of thrombocytopenia. Therefore the potential for eltrombopag to interact with cytochrome P450 activity was investigated. METHODS: Twenty-four healthy men received eltrombopag 75 mg/day on days 3-9, midazolam 5 mg (a probe for CYP3A4) on days 1 and 8 and a probe cocktail on days 2 and 9 that included caffeine 100 mg (CYP1A2), flurbiprofen 50 mg (CYP2C9) and omeprazole 20 mg (CYP2C19). RESULTS: Midazolam pharmacokinetic parameters were comparable before and after eltrombopag administration; geometric least squares (GLS) mean ratio (90% confidence intervals, CI) area under the curve from zero to infinity (AUC(0-infinity)) was 1.03 (0.94,1.12) and maximum plasma concentration (C(max)) was 0.98 (0.86,1.07). Metabolic indices for other CYP isozymes were also equivalent before and after eltrombopag. GLS mean ratio (90% CI) for the paraxanthine:caffeine concentration ratio at 8 h postdose was 0.97 (0.92,1.03), for conjugated + unconjugated and unconjugated 4-hydroxy-flurbiprofen recovery in urine over 0-8 h was 0.95 (0.93,0.97) and 0.93 (0.88,0.98), respectively, and for the plasma omeprazole:5-hydroxyomeprazole concentration ratio at 2- and 3-h postdose was 1.00 (0.93,1.08) and 1.02 (0.88,1.18), respectively. CONCLUSION: Once-daily administration of eltrombopag 75 mg for 7 days did not alter CYP3A4, CYP1A2, CYP2C9 or CYP2C19 activity in healthy volunteers.

Near-surface remote sensing of spatial and temporal variation in canopy phenology.

There is a need to document how plant phenology is responding to global change factors, particularly warming trends. "Near-surface" remote sensing, using radiometric instruments or imaging sensors, has great potential to improve phenological monitoring because automated observations can be made at high temporal frequency. Here we build on previous work and show how inexpensive, networked digital cameras ("webcams") can be used to document spatial and temporal variation in the spring and autumn phenology of forest canopies. We use two years of imagery from a deciduous, northern hardwood site, and one year of imagery from a coniferous, boreal transition site. A quantitative signal is obtained by splitting images into separate red, green, and blue color channels and calculating the relative brightness of each channel for "regions of interest" within each image. We put the observed phenological signal in context by relating it to seasonal patterns of gross primary productivity, inferred from eddy covariance measurements of surface-atmosphere CO2 exchange. We show that spring increases, and autumn decreases, in canopy greenness can be detected in both deciduous and coniferous stands. In deciduous stands, an autumn red peak is also observed. The timing and rate of spring development and autumn senescence varies across the canopy, with greater variability in autumn than spring. Interannual variation in phenology can be detected both visually and quantitatively; delayed spring onset in 2007 compared to 2006 is related to a prolonged cold spell from day 85 to day 110. This work lays the foundation for regional- to continental-scale camera-based monitoring of phenology at network observatory sites, e.g., National Ecological Observatory Network (NEON) or AmeriFlux.

Effects of food and antacids on the pharmacokinetics of eltrombopag in healthy adult subjects: two single-dose, open-label, randomized-sequence, crossover studies.

BACKGROUND: Eltrombopag is the first orally self-administered, small-molecule, nonpeptide thrombopoietin receptor agonist for the treatment of chronic idiopathic thrombocytopenic purpura. OBJECTIVE: The aim of these studies was to assess the effect of food and antacids on the pharmacokinetic and safety profiles of eltrombopag. METHODS: Two independent, single-dose, open-label, randomized-sequence, crossover studies of oral eltrombopag were conducted in healthy adult volunteers. The first study (study A) compared eltrombopag 50 mg (tablets or capsules) administered in the fasted state or tablets with a high-fat, high-calcium breakfast. The second study (study B) investigated eltrombopag tablets (75 mg) administered in the fasted state; immediately after a low-fat, low-calcium meal or a high-fat, low-calcium meal; 1 hour before a high-fat, low-calcium meal; or with an antacid containing aluminum hydroxide and magnesium carbonate. Vital signs were recorded and electrocardiogram and clinical laboratory tests were performed at screening, within 24 hours before and within 48 hours after each dose of study medication. Symptom assessment was performed and adverse events (AEs) were assessed previous to study drug administration through follow-up in terms of severity and relationship to study medication. RESULTS: In study A, 18 male subjects (mean age, 23.0 years; weight, 70.3 kg; white race, 94.4%) who received a high-fat, high-calcium breakfast had reduced bioavailability of eltrombopag in terms of AUC(0-infinity)) by 59% (geometric mean ratio [GMR], 0.41; 90% CI, 0.36-0.46) and C(max) by 65% (GMR, 0.35; 90% CI, 0.30-0.41) compared with subjects in a fasted state. In study B, the bioavailability in 26 subjects (14 male, 12 female; mean age, 35.6 years; weight, 76.0 kg; white race, 65.4%) was not significantly changed when administered with food that was low in calcium, despite the fat content (GMRs ranged from 0.87-1.03 for AUC(0-infinity) and 0.85-1.01 for C(max) across the 3 studied meals). Mean plasma AUC(0-infinity)) and C(max) values decreased by approximately 70% (GMR, 0.30; 90% CI, 0.24-0.36 for AUC(0-infinity)) and 0.24-0.38 for C(max)) when administered with a metal cation-containing antacid. No serious AEs were reported and all AEs were rated as mild to moderate in intensity. The most frequently reported AE was headache (study A, 6.3%; study B, 12.0%-29.2%). CONCLUSIONS: Concomitant administration of eltrombopag with high-calcium food or an antacid containing aluminum and magnesium was associated with significantly reduced systemic exposure, whereas low-calcium meals were not. A single dose of eltrombopag was generally well tolerated in these healthy volunteers.

Effect of eltrombopag on platelet counts and bleeding during treatment of chronic idiopathic thrombocytopenic purpura: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Eltrombopag is an oral, non-peptide, thrombopoietin-receptor agonist that stimulates thrombopoiesis, leading to increased platelet production. This study assessed the efficacy, safety, and tolerability of once daily eltrombopag 50 mg, and explored the efficacy of a dose increase to 75 mg. METHODS: In this phase III, randomised, double-blind, placebo-controlled study, adults from 63 sites in 23 countries with chronic idiopathic thrombocytopenic purpura (ITP), platelet counts less than 30 000 per muL of blood, and one or more previous ITP treatment received standard care plus once-daily eltrombopag 50 mg (n=76) or placebo (n=38) for up to 6 weeks. Patients were randomly assigned in a 2:1 ratio of eltrombopag:placebo by a validated randomisation system. After 3 weeks, patients with platelet counts less than 50 000 per microL could increase study drug to 75 mg. The primary endpoint was the proportion of patients achieving platelet counts 50 000 per microL or more at day 43. All participants who received at least one dose of their allocated treatment were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT00102739. FINDINGS: 73 patients in the eltrombopag group and 37 in the placebo group were included in the efficacy population and were evaluable for day-43 analyses. 43 (59%) eltrombopag patients and six (16%) placebo patients responded (ie, achieved platelet counts >/=50 000 per microL; odds ratio [OR] 9.61 [95% CI 3.31-27.86]; p<0.0001). Response to eltrombopag compared with placebo was not affected by predefined study stratification variables (baseline platelet counts, concomitant ITP drugs, and splenectomy status) or by the number of previous ITP treatments. Of the 34 patients in the efficacy analysis who increased their dose of eltrombopag, ten (29%) responded. Platelet counts generally returned to baseline values within 2 weeks after the end of treatment. Patients receiving eltrombopag had less bleeding at any time during the study than did those receiving placebo (OR 0.49 [95% CI 0.26-0.89]; p=0.021). The frequency of grade 3-4 adverse events during treatment (eltrombopag, two [3%]; placebo, one [3%]) and adverse events leading to study discontinuation (eltrombopag, three [4%]; placebo, two [5%]), were similar in both groups. INTERPRETATION: Eltrombopag is an effective treatment for managment of thrombocytopenia in chronic ITP.