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Background: Slow uptake of sacubitril/valsartan in patients with heart failure with reduced ejection fraction has been reported, which may negatively impact clinical outcomes. We characterized prior authorization (PA) burden, prescription copayment, and utilization of sacubitril/valsartan by insurance plan type to identify potential barriers to its use. Methods: We conducted a national population-level, cross-sectional study using PA data from an insurance coverage website accessed in March 2019 and IQVIA National Prescription Audit data from August 2018 to July 2019. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan prescriptions, and copayments per insurance plan type. Results: Overall, 48.1% (1394/2896) of insurance plans required PA for sacubitril/valsartan. Fewer Medicare (27.7%) than commercial (57.2%) plans required PA ( P P Conclusions: Despite commercial plans having greater PA requirements than Medicare, population-adjusted use of sacubitril/valsartan was higher in commercial plans. Given that commercial plans had more prescriptions with low copayments than Medicare, copayment policies may be more influential on sacubitril/valsartan use than its PA policies. Low sacubitril/valsartan use in both plan types highlights the multifactorial nature of medication underutilization that includes factors beyond the drug policies that we evaluated.

Primary aldosteronism is a secondary hypertensive disease caused by autonomous aldosterone production that often caused by an aldosterone-producing adenoma (APA). Immunohistochemistry of aldosterone synthase (CYP11B2) shows the presence of aldosterone-producing cell clusters (APCCs) even in non-primary aldosteronism adult adrenal cortex. An APCC-like structure also exists as possible APCC-to-APA transitional lesions (a speculative designation) in primary aldosteronism adrenals. However, whether APCCs produce aldosterone or 18-oxocortisol, a potential serum marker of APA, remains unknown because of lack of technology to visualize adrenocorticosteroids on tissue sections. To address this obstacle, in this study, we used highly sensitive Fourier transform ion cyclotron resonance mass spectrometry to image various adrenocorticosteroids, including 18-oxocortisol, in adrenal tissue sections from 8 primary aldosteronism patients with APCC (cases 1–4), possible APCC-to-APA transitional lesions (case 5), and APA (cases 6–8). Further analyses by tandem mass spectrometry imaging allowed us to differentially visualize aldosterone from cortisone, which share identical mass-to-charge ratio value ( m/z ). In conclusion, these advanced imaging techniques revealed that aldosterone and 18-oxocortisol coaccumulated within CYP11B2-expressing lesions. These imaging outcomes along with a growing body of aldosterone research led us to build a progressive development hypothesis of an aldosterone-producing pathology in the adrenal glands.

The degradation behavior of eight benzodiazepines (BZPs): alprazolam, etizolam, diazepam, triazolam, nitrazepam (NZP), flunitrazepam (FNZ), bromazepam, and lorazepam, in artificial gastric juice was monitored by a LC/photodiode array detector (PDA) to estimate their pharmacokinetics in the stomach. For drugs that were degradable, such physicochemical parameters as reaction rate constant were measured to evaluate the effect of storage conditions on drug degradability, such as whether the degradation proceeds faster by increasing storage temperature, or whether the degradation reaction is reversible by adjusting pH. As a result, it was confirmed that although the eight BZPs degraded in artificial gastric juice, most of them could be restored when pH was increased, and the restoration rates differed depending on the pH and the type of BZP. As for NZP, an Arrhenius plot was drawn to obtain the physicochemical parameters, such as activation energy and activation entropy involved in the degradation reaction, and the reaction kinetics was discussed. In addition, two substances were confirmed as the degradation products of NZP in artificial gastric juice: one was a reversible degradation product (A) (intermediate) and the other was an irreversible degradation product (B) (final degradation product). The intermediate was identified as 2-amino-N-(2-benzoyl-4-nitrophenyl)-acetamide, and the final degradation product was 2-amino-5-nitrobenzophenone. Therefore, when detecting NZP in human stomach contents, such as during judicial dissection, it would be prudent to target NZP as well as the intermediate (A) and the final degradation product (B).

Background: Sacubitril/valsartan (Entresto ® ) reduces mortality and heart failure (HF) admissions in NYHA Class II/III HF with reduced ejection fraction (HFrEF). However, uptake in practice has been lower than expected. Prior authorization (PA) is a common barrier that may reduce drug access, which may impact clinical outcomes. Our study characterizes PA requirement burden and use of sacubitril/valsartan by insurance plan type. Methods: We conducted a cross-sectional study using insurance plan information directly from a managed care organization-approved insurance coverage website accessed in Mar/2019 to characterize sacubitril/valsartan PA criteria in Medicare and commercial plans. We also used IQVIA National Prescription Audit data from Aug/2018 to Jul/2019 to estimate the number of prescriptions (Rx) dispensed and patient copayment for sacubitril/valsartan. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan Rx, and copayments. Data analysis was descriptive or used Chi-square. Results: For Medicare, 27.7% of plans required PA for sacubitril/valsartan, a significantly lower rate than 57.2% for commercial plans (p Conclusions: Despite commercial plans having greater PA requirements than Medicare, use of sacubitril/valsartan was higher in commercial plans. Thus, PA policies may not represent a major barrier to sacubitril/valsartan use. Given that commercial plans had more Rx with no or low copays than Medicare, copay amounts may be more influential on sacubitril/valsartan use.

The measurements of steroids in biological fluids are of importance for the diagnosis and treatment of many diseases. Liquid chromatography/electrospray ionization-tandem mass spectrometry (LC/ESI-MS/MS) has a high specificity and accuracy for the steroid analysis, whereas it has a lower analysis throughput, which could become a big issue in clinical practice. One of the promising solutions to this issue is the multiplexing of samples in the same injection. In this study, the utility of the sample-multiplexing by the derivatization using multiple analogous reagents was evaluated for enhancing the throughput of the LC/ESI-MS/MS assays of steroids. The plasma 17α-hydroxyprogesterone (17OHP), which is a diagnostic marker for the 21-hydroxylase deficiency, was chosen as the model analyte. The four plasma samples (20 μL each) were separately derivatized with one of four different analogous Girard-type reagents, combined, then injected together into the LC/ESI-MS/MS. By this method, four plasma samples could be analyzed within a single LC run. The developed method could significantly reduce the total LC run time (about 2/5 for 32 samples, compared with the conventional method) with a satisfactory sensitivity (lower limit of quantification 0.5 ng/mL), precision (intra- and inter-assay RSDs ≤ 4.0% and ≤ 3.5%, respectively) and accuracy (97.6–106.7%), and negligible matrix effect. The developed method had a satisfactory applicability for the quantification of 17OHP in the cord plasma samples.

The quantification of aldosterone (ALD) in adrenal tributary venous blood serum/plasma combined with the super-selective adrenal venous sampling (ssAVS) technique is recognized as a definitive procedure for differentiation of the forms of primary aldosteronism (PA), identification of the affected segment(s) and operating decision-making. In this study, an enhanced throughput and sensitive method was developed and validated for the quantification of ALD in ssAVS serum samples by liquid chromatography/electrospray ionization-tandem mass spectrometry (LC/ESI-MS/MS) combined with derivatization using the Girard P reagent (GP) isotopologues (2H0- and 2H5-GP). The right and left adrenal serum samples were separately pretreated and derivatized with either isotopologue. The two samples were then combined and injected together for LC/ESI-MS/MS analysis. Based on the mass differences between the isotopologues, the derivatized ALD in the two samples were quantified within a single run. This method enabled the reproducible (intra- and inter-assay relative standard deviations, 6.6% or lower) and accurate (98.2–107.0%) quantification of the serum ALD using a 25-μL sample, and the lower limit of quantification was 1.0 ng/mL. The developed method was used for the analysis of 11 pairs of ssAVS serum samples (total of 22 samples) of patients with ALD-producing adenoma and proven to have a satisfactory applicability; this method enabled the identification of the affected adrenal and the determination of the laterality of PA, and reduced the analysis time to about 2/3 compared to the previous method for 22 samples.

A method for the simultaneous determination of 25-hydroxyvitamin D3 [25(OH)D3] and its 3-sulfate [25(OH)D3S] in newborn plasma, which is expected to be helpful in the assessment of the vitamin D status, using stable isotope-dilution liquid chromatography/electrospray ionization-tandem mass spectrometry (LC/ESI-MS/MS) has been developed and validated. The plasma was pretreated based on the deproteinization and solid-phase extraction, then subjected to derivatization with 4-(4-dimethylaminophenyl)-1,2,4-triazoline-3,5-dione (DAPTAD). The derivatization enabled the accurate quantification of 25(OH)D3 without interference from 3-epi-25(OH)D3 and also facilitated the simultaneous determination of the two metabolites by LC/positive ESI-MS/MS. Quantification was based on the selected reaction monitoring with the characteristic fragmentation of the DAPTAD-derivatives during MS/MS. This method was reproducible (intra- and inter-assay relative standard deviations of 7.8% or lower for both metabolites) and accurate (analytical recovery, 95.4-105.6%). The limits of quantification were 1.0 ng/mL and 2.5 ng/mL for 25(OH)D3 and 25(OH)D3S, respectively, when using a 20-μL sample. The developed method was applied to the simultaneous determination of plasma 25(OH)D3 and 25(OH)D3S in newborns; it was recognized that the plasma concentration of 25(OH)D3S is significantly higher than that of 25(OH)D3, and preterm newborns have lower plasma 25(OH)D3S concentrations than full-term newborns.

Cinchonidine (CD)-modified palladium catalyst gave the high product ee when a commercial wet Pd/C was used after the co-evaporation pretreatment. The improvement in the ee was attributed to removal of water from a specific Pd/C interior. The use of a water-soluble CD·HCl salt resulted in the high ee without pretreatment.