ObjectiveTo assess the dose-response of daridorexant, a new dual orexin receptor antagonist, on wake after sleep onset (WASO).MethodsElderly (≥65 years) participants (n = 58) with insomnia were randomly allocated (Latin square design) to receive 5 treatments (5, 10, 25, and 50 mg daridorexant and placebo) during 5 treatment periods, each consisting of 2 treatment nights followed by a 5- to 12-day washout period. Main efficacy endpoints were the absolute change from baseline in WASO (primary) and latency to persistent sleep (LPS; secondary) to days 1 and 2 (mean of 2 treatment nights assessed by polysomnography) in each period. Safety and tolerability were also assessed.ResultsOf 58 participants included, 67% were female, and the median age was 69 years (range 65–85 years). WASO and LPS were dose-dependently reduced from baseline to days 1 and 2 after daridorexant administration (multiple comparison procedure modeling, p < 0.0001 and p = 0.004, respectively); reductions were statistically significant for doses ≥10 mg compared with placebo (WASO: −32.0, −45.1, −61.4 minutes; LPS: −44.9, −43.8, −45.4 minutes for 10, 25, and 50 mg, respectively, p ≤ 0.025). Treatment-emergent adverse events were similar for daridorexant and placebo; the most frequent were fatigue, nasopharyngitis, gait disturbance, and headache (≤7% in any group).ConclusionsDaridorexant was well tolerated. Dose-dependent improvements in WASO and LPS were statistically significant (dose range 10–50 mg) in elderly people with insomnia disorder.ClinicalTrials.gov identifier:NCT02841709.Classification of evidenceThis study provides Class I evidence that, for elderly people with insomnia, daridorexant reduced WASO.

Bone morphogenetic protein 15 (BMP15) and growth differentiation factor 9 (GDF9) are 2 closely related TGF-β ligands implicated as key regulators of follicle development and fertility. Animals harboring mutations of these factors often exhibit a blockage in follicle development beyond the primary stage and therefore little is known about the role of these ligands during subsequent (preantral) stages. Preantral follicles isolated from immature mice were cultured with combinations of BMP15, GDF9, and activin receptor-like kinase (ALK) inhibitors. Individually, GDF9 and BMP15 promoted follicle growth during the first 24 hours, whereas BMP15 subsequently (48-72 h) caused follicle shrinkage and atresia with increased granulosa cell apoptosis. Inhibition of ALK6 prevented the BMP15-induced reduction in follicle size and under basal conditions promoted a rapid increase in granulosa cell proliferation, suggesting BMP15 signals through ALK6, which in turn acts to restrain follicle growth. In the presence of GDF9, BMP15 no longer promoted atresia and in fact follicle growth was increased significantly more than with either ligand alone. This cooperative effect was accompanied by differential expression of Id1-3, Smad6-7, and Has2 and was blocked by the same ALK5 inhibitor used to block GDF9 signaling. Immunostaining for SMAD2/3 and SMAD1/5/8, representing the 2 main branches of TGF-β signaling, supported the fact that both canonical pathways have the potential to be active in growing follicles, whereas primordial follicles only express SMAD2/3. Overall results highlight differential effects of the 2 main TGF-β signaling pathways during preantral follicle growth.

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The TGFβ superfamily comprises several bone morphogenetic proteins (BMP) capable of exerting gonadotropin-independent effects on the development of small preantral follicles. In embryonic tissues, BMP concentration gradients, partly formed by antagonistic factors, are essential for establishing phenotypic fate. By examining the expression of candidate genes whose protein products are known to interact with BMP ligands, we set out to determine which antagonists would most likely contribute toward regulation of paracrine signaling during early follicle development. Juvenile mouse ovaries of 4, 8, 12, and 21 d of age enriched with follicles at successive developmental stages were used to assess changes in candidate gene transcripts by quantitative RT-PCR. Although some antagonists were found to be positively associated with the emergence of developing follicles (Nog, Htra1, Fst, Bmper, Vwc2), two (Sostdc1, Chrd) showed a corresponding reduction in expression. At each age, twisted gastrulation homolog 1 (Twsg1), Htra1, Nbl1, and Fst were consistently highly expressed and localization of these genes by in situ hybridization, and immunohistochemistry further highlighted a clear pattern of expression in granulosa cells of developing follicles. Moreover, with the exception of Nbl1, levels of these antagonists did not change in preantral follicles exposed to FSH in vitro, suggesting regulation by local factors. The presence of multiple antagonists in the juvenile ovary and their high level of expression in follicles imply the actions of certain growth factors are subject to local modulation and further highlights another important level of intraovarian regulation of follicle development.

Sterol 27‐hydroxylase (CYP27A1) is involved in bile acid synthesis and cholesterol homoeostasis. Cyp27a1 (−/−) / Apolipoprotein E (−/−) double knockout mice (DKO) fed a western diet failed to develop atherosclerosis. Caveolin‐1 (CAV‐1), the main component of caveolae, is associated with lipid homoeostasis and has regulatory roles in vascular diseases. We hypothesized that liver CAV‐1 would contribute to the athero‐protective mechanism in DKO mice. Cyp27a1 (+/+) / ApoE (−/−) (ApoE KO), Cyp27a1 (+/−) / ApoE (−/−) (het), and DKO mice were fed a western diet for 2 months. Atherosclerotic plaque and CAV‐1 protein were quantified in aortas. Hepatic Cav‐1 mRNA was assessed using qPCR, CAV‐1 protein by immunohistochemistry and western blotting. Total hepatic and plasma cholesterol was measured using chemiluminescence. Cholesterol efflux was performed in RAW264.7 cells, using mice plasma as acceptor. CAV‐1 protein expression in aortas was increased in endothelial cells of DKO mice and negatively correlated with plaque surface ( P < 0.05). In the liver, both CAV‐1 protein and mRNA expression doubled in DKO, compared to ApoE KO and het mice ( P < 0.001 for both) and was negatively correlated with total hepatic cholesterol ( P < 0.05). Plasma from DKO, ApoE KO and het mice had the same efflux capacity. In the absence of CYP27A1, CAV‐1 overexpression might have an additional athero‐protective role by partly overcoming the defect in CYP27A1‐mediated cholesterol efflux.

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