Key gaps in health economics and outcomes research best practices, decision standards, and value assessment processes are also discussed, along with next steps for evolving health economics and outcomes research practices in personalized medicine.

This study details the procedures involved in measuring a number of the componets of indole metabolism within the pineal gland. Tryptophan, 5-hydroxytryptophan, serotonin, N-acetylserotonin, melatonin, 5-hydroxyindoleacetic acid, N-acetyltransferase (NAT) activity, and hydroxyindole-O-methyltransferase activity were measured by a combination of three techniques, which included microassays, radioimmunoassay, and high-performance liquid chromatography. Determination of the melatonin synthetic pathway components within the same gland reduces the number of animals needed for studies and allows correlations between these constituents to be calculated. Very high degrees of correlation (r = 0.91-0.99) are seen between those compounds which exhibit significant rhythms (serotonin, NAT activity, N-acetylserotonin, and melatonin) when group means are compared. When correlations are calculated on a per-animal basis throughout the experiment, moderate to high degrees of correlation (r = 0.57-0.79) are found among those components that exhibit rhythms. However, when correlations are determined on a per-animal basis at each time point, no significant correlations are found. One hypothesis accounting for these differences may be that changes occur in indole metabolism within the same pineal gland over a period of a few minutes.

Precision medicine is a dynamic area embracing a diverse and increasing type of approaches that allow the targeting of new medicines, screening programs or preventive healthcare strategies, which include the use of biologic markers or complex tests driven by algorithms also potentially taking account of patient preferences. The International Society for Pharmacoeconomics and Outcome Research expanded its current work around precision medicine to (1) describe the evolving paradigm of precision medicine with examples of current and evolving applications, (2) describe key stakeholders perspectives on the value of precision medicine in their respective domains, and (3) define the core factors that should be considered in a value assessment framework for precision medicine. With the ultimate goal of improving health of well-defined patient groups, precision medicine will affect all stakeholders in the healthcare system at multiple levels spanning the individual perspective to the societal perspective. For an efficient, timely and practical precision medicine value assessment framework, it will be important to address these multiple perspectives through building consensus among the stakeholders for robust procedures and measures of value aspects, including performance of precision mechanism; aligned reimbursement processes of precision mechanism and subsequent treatment; transparent expectations for evidence requirements and study designs adequately matched to the intended use of the precision mechanism and to the smaller target patient populations; recognizing the potential range of value-generation such as ruling-in and ruling-out decisions.

The ruminant corpus luteum synthesizes and secretes oxytocin, but little is known of the regulation of these processes in the ovary. In the present work we describe a method for the preparation of cells from the early bovine corpus luteum (1-5 days postovulation) and their maintenance in serum-free culture. The release of oxytocin and progesterone from these cells was increased by the addition of insulin or insulin-like growth factor I (IGF-I), but not by IGF-II. Hormone release (measured between 60 and 84 h of culture) was increased approximately 5-fold (oxytocin) and 2.5-fold (progesterone) by maximally effective concentrations of IGF-I (EC50, 0.27 nM) and insulin (EC50, 1.94 nM). Sustained exposure (0-84 h) to prostaglandins (PGs) caused a dose-dependent reduction in oxytocin release in the presence of IGF-I (PGF2 alpha EC50, 31 nM; rank order of potency, PGF2 alpha greater than PGE2 greater than PGE1), but did not markedly reduce progesterone release. The inhibitory effect of PG on oxytocin production was mimicked by sustained exposure to a protein kinase-C activator (phorbol 12,13-dibutyrate), supporting the proposed role for this enzyme as a mediator of PG action. These data provide the first demonstration that oxytocin release from early bovine corpus luteal cell cultures can be regulated by insulin, IGF-I, and PGs. Since granulosa and/or luteal cells produce and respond to IGF-I and PGF2 alpha, our data indicate functional interaction of these compounds in the regulation of luteal cell activity.

Although patient preferences have been studied broadly for marketed products or around the time of submission to authorities and launch, patient preference studies have rarely been used during the early drug development phases. In this paper, we formulate three hypotheses supporting the use of patient preference studies in early product development: (1) integration of the patient perspective into the development process from phase 1 onwards will result in healthcare solutions with outcomes that best address patients' needs; (2) a structured process to build patient-based evidence involving partnerships between patients and other key stakeholders will improve alignment of development activities with the needs of patients; (3) quantitative patient preference research built on robust qualitative insights is necessary to strengthen development decisions in the interests of patients. To illustrate such a structured process, we describe qualitative insights research (social media analysis and online bulletin boards) and quantitative patient preference studies in dry eye disease and non-alcoholic steatohepatitis conducted during early product development by a pharmaceutical company to generate patient-based evidence. The outputs from such early patient preference studies are being used to inform patient reported outcome strategies, clinical development strategies, product design and delivery features, and form the basis for early dialog with regulators, health technology assessment (HTA) bodies and payers to ensure focus and alignment on patient-relevant endpoints. Furthermore, to discuss and theoretically substantiate our hypotheses, we review how different groups and organizations are working to embrace fully the patient perspective in product development and healthcare decision-making. The hypotheses are commensurate with the general trend toward patient-centered healthcare and the activities initiated by regulators, HTA agencies, and patient organizations. We advocate that all healthcare players should actively contribute to aligning on best practices concerning choice of methodologies and engage in multi-stakeholder dialog along the entire product development chain, to realize health technologies that best meet the needs of patients.

Objectives: Although there is increased awareness of patient and public involvement (PPI) among health technology assessment (HTA) organizations, evaluations of PPI initiatives are relatively scarce. Our objective as members of Health Technology Assessment International's (HTAi's) Patient and Citizen Involvement Group (PCIG) was to advance understanding of the range of evaluation strategies adopted by HTA organizations and their potential usefulness. Methods: In March 2016, a survey was sent to fifty-four HTA organizations through the International Network of Agencies for Health Technology Assessment (INAHTA) and contacts of members of HTAi's PCIG. Respondents were asked about their organizational structure; how patients and members of the public are involved; whether and how PPI initiatives have been evaluated, and, if so, which facilitators and challenges to evaluation were found and how results were used and disseminated. Results: Fifteen (n = 15) programs from twelve countries responded (response rate 27.8 percent) that involved patients (14/15) and members of the public (10/15) in HTA activities. Seven programs evaluated their PPI activities, including participant satisfaction (5/7), process (5/7) and impact evaluations (4/7). Evaluation results were used to improve PPI activities, identify education and training needs, and direct strategic priorities. Facilitators and challenges revolved around the need for stakeholder buy-in, sufficient resources, senior leadership, and including patients in evaluations. Conclusions: A small but diverse set of HTA organizations evaluate their PPI activities using a range of strategies that reflect the range of rationales and approaches to PPI in HTA. It will be important for HTA organizations to draw on evaluation theories and methods.

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Oxytocin is a major peptide product of the ruminant corpus luteum, and the release of oxytocin from serum-free cultures of bovine granulosa cells is stimulated by insulin and insulin-like growth factor-I (IGF-I). Here we have assessed the effects of insulin and IGF-I on oxytocin gene expression in bovine granulosa cells and the dependence of these effects on the developmental status of the cells. When cells from individual follicles were cultured, the estradiol concentration of the follicular fluid was highly correlated with insulin-stimulated oxytocin release. Subsequently, cells were pooled from follicles selected on the basis of estradiol content, and two subsets of cells were distinguished. The first contained highly differentiated cells, as judged by the high estradiol (HE-cells) concentration of the follicular fluid (greater than 40 ng/ml), high levels of LH receptors, and high hCG-stimulated cAMP accumulation. The second subset contained cells from follicles with low estradiol (less than 1 ng/ml; LE-cells) which have fewer LH receptors and low hCG-stimulated cAMP accumulation. Oxytocin production was increased more than 50-fold by insulin (EC50, 230 +/- 57 ng/ml) and IGF-I (EC50, greater than 10 ng/ml), but only in the HE-cells. Oxytocin mRNA was also greatly increased by insulin and IGF-I in the HE-cells only. In contrast, insulin and IGF-I stimulated progesterone release from both HE- and LE-cells. Since oxytocin production is a characteristic of bovine luteal cells, our results support possible roles for IGF-I and insulin in regulation of luteinization or luteal activity. The data suggest that effects of insulin and IGF-I on oxytocin production reflect their effects on oxytocin gene transcription, and that granulosa cells must be appropriately primed (presumably by the in vivo hormonal environment) before they are able to produce oxytocin in response to these polypeptides.