Evaluating REMS Burden: A Comparative Time Analysis of 3 Channels for REMS Stakeholders to Perform Mandatory REMS Tasks.

BACKGROUND: To determine the time taken to perform 5 Risk Evaluation and Mitigation Strategy (REMS) tasks across 3 channels for the Celgene REMS programs, with an aim to better understand which channels may minimize REMS administrative burden. METHODS: Five mandatory REMS tasks (new prescriber and patient enrollments, prescriber and patient surveys, and pharmacy dispenses) were performed across applicable REMS channels (online portals, telephone interactions with customer care representatives [CCRs], or an interactive voice response [IVR] system). Five REMS representatives, who had ≥1 year of experience as a CCR, simulated the completion of the same set of testing activities across REMS channels. The execution time for each task by channel was measured and averaged across the participating CCRs. RESULTS: Using the online portal, less time was taken to enroll a new prescriber (1.3 minutes) and adult male (6.7 minutes), compared to when the CCR channel was used (21.9 and 25.9 minutes, respectively). Similarly, completion of 3 AFRP prescriber surveys, the adult male patient survey, and 5 pharmacy dispenses was faster using the online portals (3.1, 1.3, and 1.7 minutes, respectively) compared to when the CCR (4.9, 1.8, and 3.4 minutes, respectively) and IVR (10.7, 4.0, and 11.3 minutes, respectively) channels were used. CONCLUSION: The use of online channels may alleviate some of the REMS burden by reducing the administrative time it takes for prescribers, patients, and pharmacy stakeholders to complete mandatory REMS tasks. More education and awareness of the available efficient channels should be provided to REMS stakeholders.

REMS pharmacy tasks: The adoption of an innovative electronic support system.

OBJECTIVES: The objective of this study was to evaluate the pharmacy adoption rates of an online Risk Evaluation and Mitigation Strategy (REMS) Pharmacy Portal designed as an alternative for REMS-certified pharmacies to perform mandatory pharmacy dispense confirmations and to assess whether Pharmacy Portal uptake was affected by the pharmacy daily dispense volume. SETTING: REMS-certified pharmacies dispensing lenalidomide (Revlimid), pomalidomide (Pomalyst), or thalidomide (Thalomid). PRACTICE DESCRIPTION: Primarily specialty and hospital pharmacies in the limited distribution network that used the REMS Pharmacy Portal. PRACTICE INNOVATION: A self-service pharmacy portal was developed to allow REMS-certified pharmacies to obtain confirmation numbers instead of calling a Celgene Customer Care Representative (CCR) or using the Interactive Voice Response System (IVR) system. EVALUATION: The numbers of pharmacy dispense confirmations obtained were identified, and the mean percentages by quarter (Q) were calculated from January 2013 through August 2016 for the Pharmacy Portal, Celgene CCR, and IVR. RESULTS: In Q1 2013, the CCR and IVR options were used for 57% and 43% of dispense confirmations, respectively. After the training period, the Pharmacy Portal rapidly became the most used option (67% of confirmations from Q2 2014). By August 2016, data displayed the continued preference for the pharmacy portal (98% of all confirmations) regardless of the daily dispense volume of the pharmacy. As of March 30, 2018, the pharmacy portal continued to be the preferred option for all pharmacies (maintained at 98.5% use). CONCLUSION: There is an overwhelming REMS pharmacy preference to use the pharmacy portal over the IVR and CCR options, irrespective of the pharmacy daily dispense volume. The rapid uptake of the pharmacy portal is most likely attributed to robust and comprehensive 1-on-1 training and support provided by the REMS sponsor to the REMS-certified pharmacies, but also because it might be easier to use than the other options, resulting in reduced REMS burden for the pharmacy.

Chemistries for Making Additive Nanolithography in OrmoComp Permissive for Cell Adhesion and Growth.

Two-photon lithography allows writing of arbitrary nanoarchitectures in photopolymers. This design flexibility opens almost limitless possibilities for biological studies, but the acrylate-based polymers frequently used do not allow for adhesion and growth of some types of cells. Indeed, we found that lithographically defined structures made from OrmoComp do not support E18 murine cortical neurons. We reacted OrmoComp structures with several diamines, thereby rendering the surfaces directly permissive for neuron attachment and growth by presenting a surface coating similar to the traditional cell biology coating achieved with poly-d-lysine (PDL) and laminin. However, in contrast to PDL-laminin coatings that cover the entire surface, the amine-terminated OrmoComp structures are orthogonally modified in deference to the surrounding glass or plastic substrate, adding yet another design element for advanced biological studies.

Protection from Below: Stabilizing Hydrogenated Graphene Using Graphene Underlayers.

We show that dehydrogenation of hydrogenated graphene proceeds much more slowly for bilayer systems than for single layer systems. We observe that an underlayer of either pristine or hydrogenated graphene will protect an overlayer of hydrogenated graphene against a number of chemical oxidants, thermal dehydrogenation, and degradation in an ambient environment over extended periods of time. Chemical protection depends on the ease of oxidant intercalation, with good intercalants such as Br2 demonstrating much higher reactivity than poor intercalants such as 1,2-dichloro-4,5-dicyanonbenzoquinone (DDQ). Additionally, the rate of dehydrogenation of hydrogenated graphene at 300 °C in H2/Ar was reduced by a factor of roughly 10 in the presence of a protective underlayer of graphene or hydrogenated graphene. Finally, the slow dehydrogenation of hydrogenated graphene in air at room temperature, which is normally apparent after a week, could be completely eliminated in samples with protective underlayers over the course of 39 days. Such protection will be critical for ensuring the long-term stability of devices made from functionalized graphene.

Kilogram-scale prexasertib monolactate monohydrate synthesis under continuous-flow CGMP conditions.

Advances in drug potency and tailored therapeutics are promoting pharmaceutical manufacturing to transition from a traditional batch paradigm to more flexible continuous processing. Here we report the development of a multistep continuous-flow CGMP (current good manufacturing practices) process that produced 24 kilograms of prexasertib monolactate monohydrate suitable for use in human clinical trials. Eight continuous unit operations were conducted to produce the target at roughly 3 kilograms per day using small continuous reactors, extractors, evaporators, crystallizers, and filters in laboratory fume hoods. Success was enabled by advances in chemistry, engineering, analytical science, process modeling, and equipment design. Substantial technical and business drivers were identified, which merited the continuous process. The continuous process afforded improved performance and safety relative to batch processes and also improved containment of a highly potent compound.

Friction between van der Waals Solids during Lattice Directed Sliding.

Nanometer-scale crystals of the two-dimensional oxide molybdenum trioxide (MoO3) were formed atop the transition metal dichalcogenides MoS2 and MoSe2. The MoO3 nanocrystals are partially commensurate with the dichalcogenide substrates, being aligned only along one of the substrate's crystallographic axes. These nanocrystals can be slid only along the aligned direction and maintain their alignment with the substrate during motion. Using an AFM probe to oscillate the nanocrystals, it was found that the lateral force required to move them increased linearly with nanocrystal area. The slope of this curve, the interfacial shear strength, was significantly lower than for macroscale systems. It also depended strongly on the duration and the velocity of sliding of the crystal, suggesting a thermal activation model for the system. Finally, it was found that lower commensuration between the nanocrystal and the substrate increased the interfacial shear, a trend opposite that predicted theoretically.

Nanopatterning of GeTe phase change films via heated-probe lithography.

The crystallization of amorphous germanium telluride (GeTe) thin films is controlled with nanoscale resolution using the heat from a thermal AFM probe. The dramatic differences between the amorphous and crystalline GeTe phases yield embedded nanoscale features with strong topographic, electronic, and optical contrast. The flexibility of scanning probe lithography enables the width and depth of the features, as well as the extent of their crystallization, to be controlled by varying probe temperature and write speed. Together, these technologies suggest a new approach to nanoelectronic and opto-electronic device fabrication.

Effectiveness of Risk Evaluation and Mitigation Strategies (REMS) for Lenalidomide and Thalidomide: Patient Comprehension and Knowledge Retention.

INTRODUCTION: The effectiveness of patient education activities conducted within the lenalidomide and thalidomide risk evaluation and mitigation strategies (REMS) programs was evaluated by measuring understanding of serious risk and safe-use messages. METHODS: Results from mandatory knowledge, attitude, and behavior surveys and voluntary patient surveys completed between June 2012 and June 2013 were analyzed, and responses to questions relating to compliance with birth control measures and understanding of safe-use messages are presented by patient risk category. RESULTS: In total, 73,645 patients were enrolled into the REMS programs for lenalidomide and thalidomide and completed mandatory surveys prior to medication dispense. Of these, 2790 (3.8%) completed an additional voluntary survey. Among voluntary survey participants, for all patient pregnancy risk categories, reported compliance with birth control requirements was above 90% when starting therapy and at follow-up. At the beginning of therapy, complete compliance was 96.3%; 3 months later it was 96.4%. Patient understanding of safe-use messages was very high in all pregnancy risk groups, notably for messages repeated at each physician visit. Overall, 98.2% of patients knew that lenalidomide and thalidomide could cause birth defects, which is part of the repeated educational messaging. In contrast, 87.1% recalled that unused product should be returned to their healthcare professional, which is not included in repeated messaging. CONCLUSION: The lenalidomide and thalidomide REMS programs enhance patient understanding of safe-use messages, resulting in high levels of compliance with the birth control precautions essential to prevent fetal exposure to these known and potential human teratogens. Overall compliance was maintained after 3 months of follow-up and throughout therapy.

Fluorinated Graphene Enables the Growth of Inorganic Thin Films by Chemical Bath Deposition on Otherwise Inert Substrates.

Chemically modified graphenes (CMGs) offer a means to tune a wide variety of graphene's exceptional properties. Critically, CMGs can be transferred onto a variety of substrates, thereby imparting functionalities to those substrates that would not be obtainable through conventional functionalization. One such application of CMGs is enabling and controlling the subsequent growth of inorganic thin films. In the current study, we demonstrated that CMGs enhance the growth of inorganic films on inert surfaces with poor growth properties. Fluorinated graphene transferred onto polyethylene enabled the dense and homogeneous deposition of a cadmium sulfide (CdS) film grown via chemical bath deposition. We showed that the coverage of the CdS film can be controlled by the degree of fluorination from less than 20% to complete coverage of the film. The approach can also be applied to other technologically important materials such as ZnO. Finally, we demonstrated that electron beam-generated plasma in a SF6-containing background could pattern fluorine onto a graphene/PE sample to selectively grow CdS films on the fluorinated region. Therefore, CMG coatings can tailor the surface properties of polymers and control the growth of inorganic thin films on polymers for the development of flexible electronics.

Transfer of Chemically Modified Graphene with Retention of Functionality for Surface Engineering.

Single-layer graphene chemically reduced by the Birch process delaminates from a Si/SiOx substrate when exposed to an ethanol/water mixture, enabling transfer of chemically functionalized graphene to arbitrary substrates such as metals, dielectrics, and polymers. Unlike in previous reports, the graphene retains hydrogen, methyl, and aryl functional groups during the transfer process. This enables one to functionalize the receiving substrate with the properties of the chemically modified graphene (CMG). For instance, magnetic force microscopy shows that the previously reported magnetic properties of partially hydrogenated graphene remain after transfer. We also transfer hydrogenated graphene from its copper growth substrate to a Si/SiOx wafer and thermally dehydrogenate it to demonstrate a polymer- and etchant-free graphene transfer for potential use in transmission electron microscopy. Finally, we show that the Birch reduction facilitates delamination of CMG by weakening van der Waals forces between graphene and its substrate.

Direct mechanochemical cleavage of functional groups from graphene.

Mechanical stress can drive chemical reactions and is unique in that the reaction product can depend on both the magnitude and the direction of the applied force. Indeed, this directionality can drive chemical reactions impossible through conventional means. However, unlike heat- or pressure-driven reactions, mechanical stress is rarely applied isometrically, obscuring how mechanical inputs relate to the force applied to the bond. Here we report an atomic force microscope technique that can measure mechanically induced bond scission on graphene in real time with sensitivity to atomic-scale interactions. Quantitative measurements of the stress-driven reaction dynamics show that the reaction rate depends both on the bond being broken and on the tip material. Oxygen cleaves from graphene more readily than fluorine, which in turn cleaves more readily than hydrogen. The technique may be extended to study the mechanochemistry of any arbitrary combination of tip material, chemical group and substrate.

Patterning magnetic regions in hydrogenated graphene via e-beam irradiation.

Partially hydrogenated graphene is ferromagnetic and may be patterned by electron-beam irradiation. Sequential patterning produces a patterned magnetic array. Removal of the hydrogen atoms also can convert electrically insulating fully hydrogenated graphene back into conductive graphene, enabling the writing of chemically isolated, dehydrogenated graphene nanoribbons as narrow as 100 nm.

van der Waals screening by single-layer graphene and molybdenum disulfide.

A sharp tip of atomic force microscope is employed to probe van der Waals forces of a silicon oxide substrate with adhered graphene. Experimental results obtained in the range of distances from 3 to 20 nm indicate that single-, double-, and triple-layer graphenes screen the van der Waals forces of the substrate. Fluorination of graphene, which makes it electrically insulating, lifts the screening in the single-layer graphene. The van der Waals force from graphene determined per layer decreases with the number of layers. In addition, increased hole doping of graphene increases the force. Finally, we also demonstrate screening of the van der Waals forces of the silicon oxide substrate by single- and double-layer molybdenum disulfide.

Nature inspires sensors to do more with less.

The world is filled with widely varying chemical, physical, and biological stimuli. Over millennia, organisms have refined their senses to cope with these diverse stimuli, becoming virtuosos in differentiating closely related antigens, handling extremes in concentration, resetting the spent sensing mechanisms, and processing the multiple data streams being generated. Nature successfully deals with both repeating and new stimuli, demonstrating great adaptability when confronted with the latter. Interestingly, nature accomplishes these feats using a fairly simple toolbox. The sensors community continues to draw inspiration from nature's example: just look at the antibodies used as biosensor capture agents or the neural networks that process multivariate data streams. Indeed, many successful sensors have been built by simply mimicking natural systems. However, some of the most exciting breakthroughs occur when the community moves beyond mimicking nature and learns to use nature's tools in innovative ways.

Graphene veils: A versatile surface chemistry for sensors.

Thin spun-coat films (~4 nm thick) of graphene oxide (GO) constitute a versatile surface chemistry compatible with a broad range of technologically important sensor materials. Countless publications are dedicated to the nuances of surface chemistries that have been developed for sensors, with almost every material having unique characteristics. There would be enormous value in a surface chemistry that could be applied generally with functionalization and passivation already optimized regardless of the sensor material it covered. Such a film would need to be thin, conformal, and allow for multiple routes toward covalent linkages. It is also vital that the film permit the underlying sensor to transduce. Here we show that GO films can be applied over a diverse set of sensor surfaces, can link biomolecules through multiple reaction pathways, and can support cell growth. Application of a graphene veil atop a magnetic sensor array is demonstrated with an immunoassay. We also present biosensing and material characterization data for these graphene veils.

Fluorination of graphene enhances friction due to increased corrugation.

The addition of a single sheet of carbon atoms in the form of graphene can drastically alter friction between a nanoscale probe tip and a surface. Here, for the first time we show that friction can be altered over a wide range by fluorination. Specifically, the friction force between silicon atomic force microscopy tips and monolayer fluorinated graphene can range from 5-9 times higher than for graphene. While consistent with previous reports, the combined interpretation from our experiments and molecular dynamics simulations allows us to propose a novel mechanism: that the dramatic friction enhancement results from increased corrugation of the interfacial potential due to the strong local charge concentrated at fluorine sites, consistent with the Prandtl-Tomlinson model. The monotonic increase of friction with fluorination in experiments also demonstrates that friction force measurements provide a sensitive local probe of the degree of fluorination. Additionally, we found a transition from ordered to disordered atomic stick-slip upon fluorination, suggesting that fluorination proceeds in a spatially random manner.

Teratogenic Drugs and Risk Management: An Implementation Assessment.

About half of all pregnant women are prescribed medication during their pregnancy, including drugs with teratogenic potential. There is a need to manage teratogenic risk and prevent fetal harm. In the US, risk management strategies may range from product labeling to the US Food and Drug Administration requiring a risk evaluation and mitigation strategy, including elements to assure safe use. The resources of these risk management controls on the health care system must be weighed against the benefits of preventing embryo-fetal exposure and birth defects. This article describes considerations for determining which risk mitigation strategies to use with teratogenic drugs and the challenges and opportunities to balance restrictions and burdens with the benefit of access to important drugs.

Outliers affecting cardiac troponin I measurement: comparison of a new high sensitivity assay with a contemporary assay on the Abbott ARCHITECT analyser.

BACKGROUND: False-positive cardiac troponin (Tn) results caused by outliers have been reported on various analytical platforms. We have compared the precision profile and outlier rate of the Abbott Diagnostics contemporary troponin I (TnI) assay with their high sensitivity (hs) TnI assay. METHODS: Three studies were conducted over a 10-month period using routine patients' samples. TnI was measured in duplicate using the contemporary TnI assay in Study 1 and Study 2 (n = 7011 and 7089) and the hs-TnI assay in Study 3 (n = 1522). Critical outliers were defined as duplicate results whose absolute difference exceeded a critical difference (CD = z x √2 x SDAnalytical) at a probability level of 0.0005, with one of the results on the opposite side of the decision limit to its partner. RESULTS: The TnI concentration at 10% imprecision (coefficient of variation) for the contemporary TnI assay was 0.034 µg/L (Study 1) and 0.042 µg/L (Study 2), and 0.006 µg/L (6 ng/L) for the hs-TnI assay. The critical outlier rates for the contemporary TnI assay were 0.51% (Study 1) and 0.37% (Study 2) using a cut-off of 0.04 µg/L, and 0% for the hs-TnI assay using gender-specific cut-offs. CONCLUSION: The significant number of critical outliers detected using the contemporary TnI assay may pose a risk for misclassification of patients. By contrast, no critical outliers were detected using the hs-TnI assay. However, the total outlier rates for both assays were significantly higher than the expected variability of either assay. The cause of these outliers remains unclear.