Head and neck squamous cell carcinoma represents a significant and growing public health problem worldwide. Head and neck squamous cell carcinoma is commonly preceded by dysplasia.  Dysplastic lesions often are found in the oral cavity in the form of erythroplakia and leukoplakia. Therefore, early detection of malignancy of the oral cavity is very important for successful treatment and improvement of the survival rate.  Fluorescence spectroscopy is a technique for evaluating the physical and chemical properties of a substance by analyzing the intensity and character of light emitted in the form of fluorescence.
Autofluorescence and diffuse reflectance spectroscopy have been studied as noninvasive in vivo tools for the detection of (pre-) malignant tissue alterations. ,,, Autofluorescence of tissues under excitation with light is produced by several endogenous fluorophores. These include fluorophores from tissue matrix molecules and intracellular molecules like collagen, elastin, keratin, FAD and NADH. The presence of disease changes the concentration of these fluorophores, which makes autofluorescence spectroscopy sensitive to tissue alterations. Diffuse reflectance is the result of single and multiple backscattering of the white excitation light. Endogenous autofluorescence has been noticed around 630 nm in tumors. This fluorescence is associated with porphyrins.  It has been demonstrated that, under the range of 325-360 nm excitation wavelength, the emission band at 400-405 nm is mainly attributed to the presence of collagen, while emission at 440-460 nm is mainly due to the presence of nicotinamide adenine dinucleotide (NADH) with an excitation wavelength at 290, 351 nm and emission at 535 nm is due to flavin adinine dinucleotide (FAD) with excitation at 450 nm and 400-405 nm excitation is for porphyrin with emission maxima at 630,690 nm  and emission at 350 nm is for tryptophan with an excitation wavelength at 280 nm [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5].
Based on this correlation of endogenous fluorophors and dysplastic and malignant lesions this study was conducted to evaluate its significance as a noninvasive diagnostic modality. We employed in vivo spectroscopy for measuring autofluorescence at 280 nm, 325 nm, 405 nm, 450 nm excitation wavelength along with diffuse reflectance study of normal, clinically diagnosed premalignant and malignant lesions of the oral cavity followed by comparison of spectroscopic results between three groups based on histopathologically diagnosed malignant lesions and clinical diagnosis or histopathologic diagnosis of premalignant lesions which was done if indicated.
To evaluate whether autofluorescence is capable of providing a higher contrast between a lesion and healthy tissue.
To evaluate the difference in fluorescence intensity of emission wavelength spectra at 280 nm, 325 nm, 405 nm and 450 nm for healthy, premalignant and malignant lesions.
To evaluate whether diffuse reflectance spectroscopy is capable of providing a higher contrast between a malignant, premalignant lesion and healthy tissue.
Autofluorescence and diffuse reflectance spectra were collected from 20 patients with a known or suspected premalignant lesion, 20 patients with a known or suspected malignant oral cavity lesion reporting to the Department of Oral Medicine and Radiology of Tamil Nadu Government Dental College and Hospital, Chennai -600003 with complaint of an oral lesion and 20 healthy volunteers with no clinically observable lesions were recruited to participate after they had given their informed consent. This study was approved by ethical committee of the Tamil Nadu Government Dental College and Hospital. The following parameters were used in the establishment of the diagnosis: The lesions were visually inspected and palpated in the head, neck, oral, and pharyngeal regions. The procedure involved digital palpation of neck node regions, bimanual palpation of the floor of mouth and tongue, and inspection with palpation and observation of the oral and pharyngeal mucosa with an adequate light source, and mouth mirrors were used for the examination. The social, familial, and medical history was documented with risk behaviors (tobacco chewing, betel quid chewing, smoking and alcohol usage), a history of head and neck radiotherapy, familial history of head and neck cancer, and a personal history of cancer was taken and recorded and patients were reassured and counseling was given along with advice to quit their habit if present.
Based on history and clinical examination clinical diagnosis of premalignant lesion including non-scrapable white lesion with habit of smoking suggestive of leukoplakia, oral submucous fibrosis, oral submucous fibrosis with lichenoid reaction or lichen planus, based on clinical features diagnosis of malignant lesion of oral cavity was given.
A monochromator with a 150-W ozone-free Xenon lamp provided the excitation light. The desired excitation wavelength and the emission spectrum were selected by PC-controlled monochromator. The excitation light was guided to illuminate samples by one arm of a Y-type quartz fiber bundle, and the emission fluorescence was collected by another arm of the fiber bundle and directed to the photo multiplier detector. The signal was then amplified and displayed on the computer monitor. Any computer that meets the required specifications can be used as the controlling (external) computer. All Fluromax - 2 functions were controlled by the DataMax software which communicates between a PC-compatible computer and the Fluromax-2 [Figure 6] and [Figure 7]. The DataMax software enables to specify the experimental parameters, acquire and display data, manage files, process data, specify the hardware components, control the spectrometers and supply high voltage to the signal detector. The optical fiber probe was disinfected with 2.4% gluteraldehyde solution, rinsed with phosphate-buffered saline, and the tip of the probe was sterilized in autoclave before using.
All spectroscopic studies were done in the Division of Medical Physics of the department of physics of Anna University Chennai-600025. The procedure was explained to all the patients before the spectroscopic study. The probe was placed in gentle contact with the oral mucosa. The measurements were performed in a completely darkened room to prevent stray light from entering the spectrograph. All patients and volunteers rinsed their mouth for 1 min with a 0.9% saline solution in order to minimize the influence of consumed food and beverages.
In this study excitation for autofluorescence spectroscopy was done with ultraviolet light excitation at 280 nm, 325 nm and visible light excitation at 405 nm and 450 nm. The resulting emission spectra were recorded from 325 nm to 70 0nm in 1-mm increments. For diffuse reflectance measurements - Diffuse reflectance spectra in the range of 270-700 nm were analyzed using a model based on light diffusion theory to extract the absorption and reduced scattering coefficients of tissue. Following spectroscopic measurements, biopsy was done for all sites interrogated with the fiber-optic probe. Histopathology examination was done in the Department of Oral Pathology of Tamil Nadu Government Dental College. Biopsies were always performed after the spectra had been acquired so as not to influence the spectra. Histopathology was considered for thick, homogenous, speckled leukoplakia, OSMF with lichenoid reaction, erosive and erythematous lesions and malignant lesions, and for other premalignant lesions diagnosis was obtained by clinical inspection. However, all dysplastic and malignant lesions were histologically proven. Based on histopathologic examination diagnosis of premalignant lesions was specified as dyspastic or no dysplastic changes; and all malignant lesions were specified as mild, moderate or well-differentiated squamous cell carcinoma.
Autofluorescence data were analyzed to determine which excitation and emission wavelengths showed significant difference between the three groups. Statistical analysis was done based on peak fluorescence intensity seen in spectrograph by taking into account the ratio of two peaks seen within one spectrograph at 280 nm, 325 nm and 405nm excitation wavelength. Comparison of fluorescence intensity was done at 450 nm excitation because at this wavelength no evidence of significant peak in emission was seen. Comparison of fluorescence intensity was done for diffuse reflectance for three groups. All tests were done utilizing one-way ANOVA test followed by post hoc tests for multiple comparisons between groups.
This study enrolled 60 subjects which included 20 normal, 20 clinically diagnosed premalignant lesions and 20 clinically diagnosed malignant lesions of the oral cavity. Age range for malignant group was 36 to 75 years, for premalignant group was 31 to 62 years and for normal mucosa, the range was 28 to 42 years. Our study group for malignant lesions included five females and 15 males, premalignant lesions included two females and 18 males and the normal mucosa group included eight females and 12 males.
Excitation in ultraviolet spectrum was given at 280 nm and 325 nm and excitation at visible light spectrum was given at 405 nm and 450 nm. A continuous excitation at ultraviolet and visible light was given to asses diffuse reflectance. All spectrographs were compared between malignant lesions, premalignant lesions and normal mucosa for autofluorescence and diffuse reflectance.
Shape of emission spectrum for malignant, premalignant and normal mucosa was almost similar with peak in intensity seen at 340 nm and 468 nm. Variability in fluorescence intensity was seen in the spectrum of premalignant, malignant lesions and normal mucosa. Average of emission peak ratio at 340 nm (+5 / -5 nm) and 468 nm (+5 / -5nm) was considered as R1 for excitation at 280 nm. ANOVA test revealed significant difference between R1 of the three groups with P value of .000 suggestive of 99.9% significant difference. This was followed by post hoc analysis which revealed a significant difference between carcinoma and premalignant lesions with P value of .004 suggestive of 99% significant difference, and P value .000 was present between carcinoma and normal group suggestive of 99.9% significant difference. R1 value was higher for carcinoma than it decreases for premalignant lesions and than for normal mucosa.
Shape of spectrum for malignant, premalignant and normal mucosa was almost similar with peak in intensity seen at 468 nm and at 560 nm. Variability in fluorescence intensity was seen in spectrum of premalignant, malignant lesions and normal mucosa. Average of emission peak ratio at 468 nm (+5 /-5nm) and 560nm (+5/-5nm) was considered as R2 for excitation at 325 nm. Significant difference was seen at 325 nm excitation. ANOVA test revealed 99% significant difference between the three groups with P value of 0.002. This was followed by post hoc tests which showed a significant difference between carcinoma and premalignant lesions with a P value of 0.01 suggestive of 99% significant difference, and P value 0.004 was present between the carcinoma and normal group suggestive of 99% significant difference. R2 value was lowest for carcinoma than it increases for premalignant lesions and than for normal mucosa.
Shape of spectrum for premalignant and normal mucosa was almost similar with peak in intensity seen at 468 nm and at 636 nm for malignant lesions while premalignant lesions and normal mucosa showed peak at 468 nm only and mild peak was seen at 636 nm for premalignant lesions. Variability in fluorescence intensity was seen in spectrum of premalignant, malignant lesions and normal mucosa. Average of emission peak ratio at 468 nm (+5 / -5nm) and 636 nm (+5/ -5nm) was considered as R3 for excitation at 405 nm. R3 for carcinoma, premalignant lesions and normal mucosa was compared using ANOVA test followed by post hoc test to analyze the significant difference at 405 nm excitation. ANOVA test showed 99.9% significant difference within the three groups. Post hoc tests showed a significant difference between carcinoma and premalignant lesions with a P value of 0.01 suggestive of 99% significant difference, and P value 0.004 was present between the carcinoma and normal group suggestive of 99% significant difference. R3 value was lowest for carcinoma than it increases for premalignant lesions and than for normal mucosa.
Shape of spectrum for malignant, premalignant and normal mucosa was almost similar with peak in intensity seen at 493 nm which was just followed by a dip at 487 nm. Variability in fluorescence intensity was seen in the spectrum of premalignant, malignant lesions and normal mucosa. Fluorescence spectroscopy at 450 nm excitation revealed peak at 468 nm with no evidence of any other peak. Statistical analysis done by comparing the fluorescence intensity between the carcinoma group, premalignant lesions and normal mucosa using ANOVA test revealed 99% significant difference within groups with P value of 0.004. Post hoc tests revealed significant difference between carcinoma and normal mucosa with P value of 0.03. Fluorescent intensity was highest for normal mucosa and it decreased for premalignant lesions followed by malignant lesions.
Shape of spectrograph was almost similar for malignant, premalignant and normal mucosa with dip seen in all emission spectra at 468 nm. Variability in intensity of emission was seen for malignant lesions, premalignant lesions as well as normal mucosa. Emission spectrum intensity comparison was done for carcinoma group, premalignant group and normal mucosa group using ANOVA test and post hoc test. ANOVA test revealed 99% significant difference between the three groups with P value 0.006 and post hoc tests revealed significant difference between carcinoma group and normal mucosa group with P value of 0.004, suggestive of 99% significant difference between both groups. With higher intensity was observed for carcinoma group than it was decreasing from premalignant group and further decrease in intensity was observed for normal mucosa group.
This study identified a significant difference between malignant lesions, premalignant lesions and normal mucosa with fluorescence spectroscopy and diffuse reflectance.
At 280 nm excitation emission peak was seen at 340 nm and mild peak was seen at 468 nm. This emission at 340 nm was due to tryptophan as proteins absorb light near 280 nm and fluorescence emission maxima range from 320 nm to 350 nm. The tryptophan residues of proteins generally account for about 90% of the total fluorescence from proteins.  Ratio of emission at 340 nm (+/-5nm) and 468 nm (+/-5nm) was considered as R1. One-way ANOVA test revealed significant difference of 99.9% between the three groups for R1. Comparison of fluorescence spectrograph between the three groups revealed decreasing intensity from premalignant to normal to carcinoma group suggestive of increased tryptophan in premalignant compared to malignant group and tryptophan in normal mucosa is more than malignant mucosa.
Excitation at 450 nm revealed no evidence of significant peak. So, no evidence of FAD emission was seen in any of the group as FAD shows emission maxima at 535 nm when excitation maxima is 450 nm. Hence intensity for the carcinoma group, premalignant group and normal mucosa group was compared using one-way ANOVA test which revealed 99% significant difference between groups followed by post hoc test which showed significant difference between the normal and carcinoma group. Increasing order of fluorescence intensity was seen from the carcinoma group to premalignant group to normal group and excitation at 450 nm was considered for FAD with emission maxima at 515-535 nm. Although our study was inconsistent with emission maxima our observation at 450 nm excitation was consistent with Richahrds-Kortum et al. They found that the fluorescence intensity was lower for neoplastic lesions than for normal mucosa.  Comparison of fluorescence spectra between the three groups also revealed decrease in fluorescence intensity from normal to premalignant to malignant lesions.
Spectroscopy study for diffuse reflectance showed a significant difference between the three groups with decrease in fluorescence intensity from carcinoma to premalignant to normal mucosa group. Higher fluorescence intensity in lesions than normal mucosa could be due to hyperkeratosis and increased epithelial thickness. Although our results were inconsistent with previous studies which show that there was decrease in fluorescence intensity from normal to premalignant to malignant group which could be attributed to increase in absorption and less reflectance because of increase in vascularity in the premalignant and malignant group. There was no evidence of significant difference between kerartinized and non-keratinized epithelium results within the carcinoma group.
There are several possible explanations for the large intra- and inter-subject variability in total fluorescence intensity. Fluorescence intensity can be influenced by intersubject variability in the amount of blood, with absorption leading to a wavelength-dependent decrease in fluorescence intensity. Besides the biological variation, varying experimental circumstances can influence the total fluorescence intensity. Also, our study sample was comparatively small and within the group itself there was variability in oral lesions like the carcinoma group included two verrucous carcinoma, 13 well-differentiated and five moderately differentiated squamous cell carcinoma and the premalignant group consisted of two OSMF, two OSMF with lichenoid reactions, two dysplastic leukoplakia, one erosive lichen planus and 13 leukoplakia cases.
The current study used fluorescence and reflectance spectra of the oral cavity to extract quantitative biochemical and morphologic features associated with carcinoma progression. The rich source of information and diagnostic potential provided by noninvasive spectroscopic techniques allows us to understand more fully the changes that take place during the onset and progression of neoplasia. The results of our study demonstrated that autofluorescence due to tryptophan; collagen, NADH, FAD, porphyrin and diffuse reflectance changes has excellent diagnostic potential. Because this technique can discriminate between malignant, premalignant epithelial lesions and healthy mucosa, it could be used as a diagnostic modality to differentiate between malignant and premalignant epithelial lesions and to define margins of resection for various surgical procedures. Additionally, this technique could also be used to monitor the response of tissues to various therapeutic interventions.
However, the results of our study on autofluorescence and diffuse reflectance characteristics in the diagnosis of malignant and premalignant epithelial lesions can be validated with more studies involving large samples and with more homogenous samples.
1. Boone CW, Bacus JW, Bacus JV, Steele VE, Kelloff GJ. Properties of intraepithelial neoplasia relevant to cancer chemoprevention chemoprevention and to the development of surrogate end points for clinical trials. Proc Soc Exp Biol Med 1997;216:151-65.
2. Silverman S Jr. Oral cancer. 4 th ed. London: BC Decker Inc.; 1998. p. 70-5.
3. Bouquot JE, Kurland LT, Weiland LH. Carcinoma in situ of the upper aerodigestive tract. Incidence, time trends, and follow-up in Rochester, Minnesota, 1935-1984. Cancer 1988;61:1691-8.
4. Leunig A, Betz CS, Mehlmann M, Stepp H, Arbogast S, Grevers G, et al. Detection of squamous cell carcinoma of the oral cavity by imaging 5-aminolevulinic acid-induced protoporphyrin IX fluorescence. Laryngoscope 2000;110:78-83.
5. Georgakoudi I, Jacobson BC, Mόller MG, Sheets EE, Badizadegan K, Carr-Locke DL, et al. NAD(P)H and collagen as in vivo quantitative fluorescent biomarkers of epithelial precancerous changes. Cancer Res 2002;62:682-7.
6. DeClerck YA. Interaction between tumour cells and stromal cells and proteolytic Modification of the extracellular matrix by metalloproteinases in cancer. Eur J Cancer 2000;36:1258-68.
7. Mayinger B, Jordan M, Horner P, Gerlach C, Muehldorfer S, Bittorf BR, et al. Endoscopic light-induced autofluorescence spectroscopy for the diagnosis of colorectal cancer and adenoma. J Photochem Photobiol B 2003;70:13-20.
8. Wang CY, Tsai T, Chen HM, Chen CT, Chiang CP. PLS-ANN based classification model for oral submucous fibrosis and oral carcinogenesis. Lasers Surg Med 2003;32:318-26.
9. Zellweger M, Grosjean P, Goujon D, Monnier P, van den BH, Wagnieres G. In vivo autofluorescence spectroscopy of human bronchial tissue to optimize the detection and imaging of early cancers. J Biomed Opt 2001;6:41-51.
10. Zonios G, Perelman L, Backman V, Manoharan R, Fitzmaurice M, Van Dam J, Feld MS. Diffuse reflectance spectroscopy of human adenomatous colon polyps in vivo. Appl Opt-OT 1999;38:6628-37.
11. De Veld DC, Witjes MJ, Sterenborg HJ, Roodenburg JL. The status of in vivo autofluoroscence spectroscopy and imaging for oral oncology. Oral Oncology 2005;41:117-31.
12. Ramanujam N. Fluoroscence spectroscopy of neoplastic and non-neoplastic tissues. Neoplasia 2000;2:89-117.
13. Jablonsky book of spectroscopy. Chapter 1. Introduction to fluorescence. Principles of spectroscopy, 1 st ed.
14. Swinson B, Jerjes W, El-Maaytah M, Norris P, Hopper C. Optical techniques in diagnosis of head and neck malignancy. Oral Oncology 2006;42:221-8.
15. Svistun E, Alizadeh-Naderi R, El-Naggar A, Jacob R, Gillenwater A, Richards-Kortum R. Vision enhancement system for detection oral cavity neoplasia based on autofluorscemnce; Wiley Interscience, Available from: www.interscience.wiley.com. [last cited on 2004 Feb 4].
16. de Veld DC, Skurichina M, Witjes MJ, Duin RP, Sterenborg DJ, Star WM, et al. Autofluorescence characteristics of healthy oral mucosa at different anatomical sites. Lasers Surg Med 2003;32:367-76.
17. Wu Y, Qu JY. Autofluorescence spectroscopy of epithelial tissues. J Biomed Opt 2006;11:054023.
18. Ramanujam N. Fluorescence spectroscopy of neoplastic and non-neoplastic tissues. Neoplasia 2000;2:89-117.


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June 8, 2019 2:45 am / Leave a comment
MF C24H26N4O3S
MW 450.55
8-Quinolinesulfonamide, N-[4-[[4-(cyclopropylmethyl)-1-piperazinyl]carbonyl]phenyl]-
N-[4-[[4-(Cyclopropylmethyl)-1-piperazinyl]carbonyl]phenyl]-8-quinolinesulfonamide
Originator Agios Pharmaceuticals
Class Antianaemics; Piperazines; Quinolines; Small molecules; Sulfonamides
Mechanism of Action Pyruvate kinase stimulants
Orphan Drug Status Yes – Inborn error metabolic disorders
Phase III Inborn error metabolic disorders
Phase II Thalassaemia
27 Feb 2019 Agios Pharmaceuticals plans a phase III trial for Inborn error metabolic disorders (Pyruvate kinase deficiency) (Treatment-experienced) in the US, Brazil, Canada, Czech Republic, Denmark, France, Germany, Ireland, Italy, Japan, South Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, Turkey and United Kingdom in March 2019 (NCT03853798) (EudraCT2018-003459-39)
11 Dec 2018 Phase-II clinical trials in Thalassaemia in Canada (PO) (NCT03692052)
29 Aug 2018 Chemical structure information added
Activator of pyruvate kinase isoenzyme M2 (PKM2), an enzyme involved in glycolysis. Since all tumor cells exclusively express the embryonic M2 isoform of PK, it is hypothesized that PKM2 is a potential target for cancer therapy. Modulation of PKM2 might also be effective in the treatment of obesity, diabetes, autoimmune conditions, and antiproliferation-dependent diseases.
Agios Pharmaceuticals is developing AG-348 (in phase 3 , in June 2019), an oral small-molecule allosteric activator of the red blood cell-specific form of pyruvate kinase (PK-R), for treating PK deficiency and non-transfusion-dependent thalassemia.
WO 20100331307
CAS 59878-57-8 TO CAS 57184-25-5
Eisai Co., Ltd., EP1508570, Lithium aluminium hydride (770 mg, 20.3 mmol) was suspended in tetrahydrofuran (150 mL), 1-(cyclopropylcarbonyl)piperazine (1.56 g, 10.1 mmol) was gradually added thereto, and the reaction mixture was heated under reflux for 30 minutes. The reaction mixture was cooled to room temperature, and 0.8 mL of water, 0.8 mL of a 15percent aqueous solution of sodium hydroxide and 2.3 mL of water were seque ntially gradually added thereto. The precipitated insoluble matter was removed by filtration through Celite, and the filtrate was evaporated to give the title compound (1.40g) as a colorless oil. The product was used for the synthesis of (8E,12E,14E)-7-((4-cyclopropylmethylpiperazin-1-yl)carbonyl)oxy-3,6,16,21-tetrahydroxy-6,10,12,16,20-pentamethyl-18,19-epoxytricosa-8,12,14-trien-11-olide (the co mpound of Example 27) without further purification.1H-NMR Spectrum (CDCl3,400MHz) delta(ppm): 0.09-0.15(2H,m), 0.48-0.56(2H,m),0.82-0.93(1H,m),2.25(2H,d,J=7.2Hz) 2.48-2.65(4H,m),2.90-2.99(4H,m).
CAS 91-22-5 TO CAD 18704-37-5
chlorosulfonic acid;
Russian Journal of Organic Chemistry, vol. 36, 6, (2000), p. 851 – 853
Yield : 52%1-Step Reaction
dimethylsulfoxide-d6, 1H
1H NMR (400 MHz, DMSO-d6) δ: 1.2 (t, 2H), 1.3 (t, 2H), 1.31-1.35 (m, 1H), 2.40 (s, 2H), 3.68 (br s, 4H), 3.4-3.6 (m, 4H), 7.06 (m, 6H), 7.25-7.42 (m, 3H), 9.18 (s, 1H) 10.4 (s, 1H)
1H NMR (400 MHz, DMSO-d6) δ: 0.04-0.45 (m, 2H), 0.61-0.66 (m, 2H), 1.4-1.6 (m, 1H), 2.21-2.38 (m, 4H), 2.61 (d, 2H), 3.31-3.61 (br s, 4H), 6.94-7.06 (m, 4H), 7.40 (d, 2H), 7.56-7.63 (m, 2H), 8.28 (d, 1H), 9.18 (s, 1H), 10.4 (s, 1H)
Mitapivat (designated AG 348), an orally available, first-in-class, small molecule stimulator of pyruvate kinase (PK), is being developed by Agios Pharmaceuticals for the treatment of pyruvate kinase deficiency (Inborn error metabolic disorders in development table) and thalassemia. Mitapivat is designed to activate the wild-type (normal) and mutated PK-R (the isoform of pyruvate kinase that is present in erythrocytes), in order to correct the defects in red cell glycolysis found within mutant cells. Clinical development is underway for inborn error metabolic disorders in the US, Spain and Denmark and for Thalassaemia in Canada.
Mitapivat emerged from Agios' research programme focussed on the discovery of small molecule therapeutics for inborn metabolic disorders [see Adis Insight Drug Profile 800036791].
In April 2017, the US FDA granted fast track designation to mitapivat for the treatment of pyruvate kinase deficiency
In June 2018, Agios Pharmaceuticals initiated the phase III ACTIVATE trial to evaluate the efficacy and safety of orally administered mitapivat as compared with placebo in participants with pyruvate kinase deficiency (PKD), who are not regularly receiving blood transfusions (NCT03548220; AG348-C-006). The randomised, double-blind, placebo-controlled global trial intends to enrol 80 patients in the US, Canada, Denmark, France, Germany, Italy, Japan, South Korea, Netherlands, Poland, Portugal, Spain, Switzerland, Thailand and United Kingdom. The study design has two parts. Part 1 is a dose optimisation period where patients start at 5mg of mitapivat or placebo twice daily, with the flexibility to titrate up to 20mg or 50mg twice daily over a three month period to establish their individual optimal dose, as measured by maximum increase in hemoglobin levels. After the dose optimisation period, patients will receive their optimal dose for an additional three months in part 2. The primary endpoint of the study is the proportion of patients who achieve at least a 1.5 g/dL increase in haemoglobin sustained over multiple visits in part 2 of the trial
In February 2018, Agios Pharmaceuticals initiated the phase III ACTIVATE-T trial to assess the efficacy and safety of mitapivat in regularly transfused adult subjects with pyruvate kinase deficiency (Inborn error metabolism disorders in development table) (EudraCT2017-003803-22; AG348-C-007). The open label trial will enrol approximately 20 patients in Denmark and Spain and will expand to Canada, France, Italy, Japan, the Netherlands, the UK and the US
In December 2018, Agios Pharmaceuticals initiated a phase II study to assess the safety, efficacy, pharmacokinetics and pharmacodynamics of mitapivat (50mg and 100mg) for the treatment of patients with non-transfusion-dependent thalassemia (AG348-C-010; EudraCT2018-002217-35; NCT03692052). This study will include a 24-week core period followed by a 2-year extension period for eligible participants. The open-label trial intends to enrol approximately 17 patients. Enrolment has been initiated in Canada and may expand to the US and the UK
Agios Pharmaceuticals, in June 2015 initiated the phase II DRIVE PK trial to evaluate the safety, efficacy, pharmacokinetics and pharmacodynamics of mitapivat in adult transfusion-independent patients with pyruvate kinase deficiency (Inborn error metabolism disorders in development table) (AG348-C-003; NCT02476916). The trial will include two arms with 25 patients each. The patients in the first arm will receive 50mg twice daily, and the patients in the second arm will receive 300mg twice daily. The study will include a six-month dosing period with the opportunity for continued treatment beyond six months based on safety and clinical activity. The open-label, randomised trial completed enrolment of targeted 52 patients in the US, in November 2016. Preliminary data from the trial was presented at the 21st Congress of the European Haematology Association (EHA-2016). Updated results were presented by Agios at the 58th Annual Meeting and Exposition of the American Society of Haematology in December 2016. Based on results of the DRIVE PK trial, Agios plans to develop a registration path for mitapivat. Updated data from the trial was presented at the 22nd Congress of the European Haematology Association (EHA-2017)
In December 2017, Agios pharmaceuticals presented updated safety and efficacy data from this trial at the 59th Annual Meeting and Exposition of the American Society of Hematology (ASH- Hem 2017). Results showed that chronic daily dosing with mitapivat has been well tolerated and has resulted in clinically relevant, durable increases in Hb and reductions in markers of haemolysis across a range of doses
In June 2018, Agios Pharmaceuticals completed a phase I trial in healthy male volunteers to assess the absorption, distribution, metabolism, excretion and absolute bioavailability of AG 348 (AG348-C-009; NCT03703505). Radiolabelled analytes of AG 348 ([14C]AG 348 and [13C6]AG 348) were administered in a single oral and intravenous dose on day 1. The open label trial was initiated in May 2018 and enrolled 8 volunteers in the US
In November 2017, Agios Pharmaceuticals completed a phase I trial that evaluated the relative bioavailability and safety of the mitapivat tablet and capsule formulations after single-dose administration in healthy adults (AG348-C-005; NCT03397329). The open-label trial enrolled 26 subjects in the US and was initiated in October 2017
In October 2017, Agios Pharmaceuticals completed a phase I trial that evaluated the pharmacokinetics, safety and effect on QTc interval of mitapivat in healthy volunteers (AG348-C-004; NCT03250598). This single-dose, open-label trial was initiated in August 2017 and enrolled 60 volunteers in the US
In November 2014, Agios completed a randomised, double-blind, placebo-controlled phase I trial that assessed the safety, pharmacokinetics and pharmacodynamics of multiple escalating doses of mitapivat in healthy volunteers (MAD; AG-348MAD; AG348-C-002; NCT02149966). Mitapivat was dosed daily for 14 days. The trial recruited 48 subjects in the US. In June 2015, positive results from the trial were presented at the 20th congress of the European Haematology Association (EHA-2015). Mitapivat showed a favourable pharmacokinetic profile with rapid absorption, low to moderate variability and a dose-proportional increase in exposure following multiple doses and serum hormone changes consistent with reversible aromatase inhibition were also observed
Agios Pharmaceuticals completed a randomised, double-blind, placebo-controlled phase I clinical trial of mitapivat in August 2014 (AG-348 SAD; AG348-C-001; NCT02108106). The study evaluated the safety, pharmacokinetics and pharmacodynamics of single escalating doses of the agent in healthy volunteers. Potential metabolic biomarkers were also explored. The trial enrolled 48 participants in the US
IND-enabling studies were conducted in 2013 In December 2013, Agios presented data from in vitro studies at the 55th Annual Meeting and Exposition of the American Society of Hematology (ASH-Hem-2013), showing that mitapivat activates a range of pyruvate kinase mutant proteins in blood samples taken from patients with pyruvate kinase deficiency. The company hypothesised that mitapivat may restore the glycolytic pathway activity and normalise erythrocyte metabolism in vivo The US FDA granted orphan designation for mitapivat for the treatment of pyruvate kinase deficiency. The designation was granted to Agios Pharmaceuticals, in March 2015.
As of January 2018, Agios Pharmaceuticals owned approximately six issued US patents, 65 issued foreign patents, five pending US patent applications and 55 pending foreign patent applications in a number of jurisdictions directed to PK deficiency programme, including mitapivat (AG 348). The patents are valid till at least 2030
US 20100331307 A1
WO 2011002817 A1
WO2011002817
Mitapivat, also known as PKM2 activator 1020, is an activator of a pyruvate kinase PKM2, an enzyme involved in glycolysis. It was disclosed in a patent publication WO 2011002817 A1 as compound 78.
WO2019099651 ,
WO-2019104134
Novel crystalline and amorphous forms of N-(4-(4-(cyclopropylmethyl)piperazine-1-carbonyl)phenyl)quinoline-8-sulfonamide (also known as mitapivat ) and their hemi-sulfate, solvates, hydrates, sesquihydrate, anhydrous and ethanol solvate (designated as Form A-J), processes for their preparation and compositions comprising them are claimed. Also claims are their use for treating pyruvate kinase deficiency, such as sickle cell disease, thalassemia and hemolytic anemia.
Pyruvate kinase deficiency (PKD) is a disease of the red blood cells caused by a deficiency of the pyruvate kinase R (PKR) enzyme due to recessive mutations of PKLR gene (Wijk et al. Human Mutation, 2008, 30 (3) 446-453). PKR activators can be beneficial to treat PKD, thalassemia (e.g., beta-thalessemia), abetalipoproteinemia or Bassen-Kornzweig syndrome, sickle cell disease, paroxysmal nocturnal hemoglobinuria, anemia (e.g., congenital anemias (e.g., enzymopathies), hemolytic anemia (e.g. hereditary and/or congenital hemolytic anemia, acquired hemolytic anemia, chronic hemolytic anemia caused by phosphoglycerate kinase deficiency, anemia of chronic diseases, non- spherocytic hemolytic anemia or hereditary spherocytosis). Treatment of PKD is supportive, including blood transfusions, splenectomy, chelation therapy to address iron overload, and/or interventions for other disease-related morbidity. Currently, however, there is no approved medicine that treats the underlying cause of PKD, and thus the etiology of life-long hemolytic anemia.
[0003] N-(4-(4-(cyclopropylmethyl)piperazine-l-carbonyl)phenyl)quinoline-8-sulfonamide, herein referred to as Compound 1, is an allosteric activator of red cell isoform of pyruvate kinase (PKR). See e.g., WO 2011/002817 and WO 2016/201227, the contents of which are incorporated herein by reference.
(Compound 1)
[0004] Compound 1 was developed to treat PKD and is currently being investigated in phase 2 clinical trials. See e.g., U.S. clinical trials identifier NCT02476916. Given its therapeutic benefits, there is a need to develo
Compound 1, i.e., the non-crystalline free base, can be prepared following the procedures described below.
Preparation of ethyl -4-(quinoline-8-sulfonamido) benzoate
EtO TV
[00170] A solution containing ethyl-4-aminobenzoate (16. Og, 97mmol) and pyridine (l4.0g, l77mmol) in acetonitrile (55mL) was added over 1.2 hours to a stirred suspension of quinoline- 8 -sulfonyl chloride (20.0g, 88mmol) in anhydrous acetonitrile (100 mL) at 65°C. The mixture was stirred for 3.5 hours at 65 °C, cooled to 20°C over 1.5 hours and held until water (140 mL) was added over 1 hour. Solids were recovered by filtration, washed 2 times (lOOmL each) with acetonitrile/water (40/60 wt./wt.) and dried to constant weight in a vacuum oven at 85°C. Analyses of the white solid (30.8g, 87mmol) found (A) HPLC purity = 99.4% ethyl -4-(quinoline-8-sulfonamido) benzoate, (B) LC-MS consistent with structure, (M+l)= 357 (C18 column eluting 95-5, CH3CN/water, modified with formic acid, over 2 minutes), and (C) 1H NMR consistent with structure (400 MHz, DMSO-i 6) = d 10.71 (s, 1H), 9.09 (dd, 7 = 4.3, 1.6 Hz, 1H), 8.46 (ddt, 7 = 15.1, 7.3, 1.5 Hz, 2H), 8.26 (dd, 7 = 8.3, 1.4 Hz, 1H), 7.84 – 7.54 (m, 4H), 7.18 (dd, 7 = 8.6, 1.3 Hz, 2H), 4.26 – 4.07 (m, 2H), 1.19 (td, 7 = 7.1, 1.2 Hz, 3H).
Preparation of 4-(quinoline-8-sulfonamide) benzoic acid
[00171] A NaOH solution (16.2g, l22mmol) was added over 30 minutes to a stirred suspension of ethyl -4-(quinoline-8-sulfonamido) benzoate (20. Og, 56.2mmol) in water (125 mL) at 75°C. The mixture was stirred at 75°-80°C for 3 hours, cooled 20°C and held until THF (150 mL) was added. Hydrochloric acid (11% HCL, 8lmL, l32mmol) was added over >1 hour to the pH of 3.0. The solids were recovered by filtration at 5°C, washed with water (2X lOOmL) and dried to constant weight in a vacuum oven at 85°C. Analysis of the white solid (16.7g, 51 mmol) found (A) HPLC puurity = >99.9% 4-(quinoline-8-sulfonamide)benzoic acid, LC-MS consistent with structure (M+l) = 329 (Cl 8 column eluting 95-5 CH3CN/water, modified with formic acid, over 2 minutes.) and 1H NMR consistent with structure (400 MHz, DMSO-76) = d 12.60 (s, 1H), 10.67 (s, 1H), 9.09 (dd, 7 = 4.2, 1.7 Hz, 1H), 8.46 (ddt, 7 = 13.1, 7.3, 1.5 Hz, 2H), 8.26 (dd, 7 = 8.2, 1.5 Hz, 1H), 7.77 -7.62 (m, 3H), 7.64 (d, 7 = 1.3 Hz, 1H), 7.16 (dd, 7 = 8.7, 1.4 Hz, 2H).
Preparation of l-(cyclopropylmethyl)piperazine dihydrochloride (4)
1 ) NaBH(OAc)3
2 3 acetone 4
[00172] To a 1 L reactor under N2 was charged tert-butyl piperazine- l-carboxylate (2) (100.0 g, 536.9 mmol), cyclopropanecarbaldehyde (3) (41.4 g, 590.7 mmol ), toluene (500.0 mL) and 2-propanol (50.0 mL). To the obtained solution was added NaBH(OAc)3 (136.6 g, 644.5 mmol) in portions at 25-35 °C and the mixture was stirred at 25 °C for 2 h. Water (300.0 mL) was added followed by NaOH solution (30%, 225.0 mL) to the pH of 12. The layers were separated and the organic layer was washed with water (100.0 mLx2). To the organic layer was added hydrochloric acid (37%, 135.0 mL, 1.62 mol) and the mixture was stirred at 25 °C for 6 h. The layers were separated and the aqueous layer was added to acetone (2.0 L) at 25 °C in lh. The resulted suspension was cooled to 0 °C. The solid was filtered at 0 °C, washed with acetone (100.0 mLx2) and dried to afford 4 (105.0 g) in 92% isolated yield. LC-MS (C18 column eluting 90-10 CH3CN/water over 2 minutes) found (M+l) =141. 1H NMR (400 MHz, DMSO-76) d 11.93 (br.s, 1H), 10.08 (br., 2H), 3.65 (br.s, 2H), 3.46 (br.s, 6H), 3.04 (d, / = 7.3 Hz, 2H), 1.14 – 1.04 (m, 1H), 0.65 – 0.54 (m, 2H), 0.45 – 0.34 (m, 2H) ppm.
Preparation of N-(4-(4-(cyclopropylmethyl)piperazine-l-carbonyl)phenyl)quinoline-8- sulfonamide (1)
[00173] To a 2 L reactor under N2 was charged 4-(quinoline-8-sulfonamido) benzoic acid (5) (100.0 g, 304.5 mmol) and DMA (500.0 mL). To the resulted suspension was added CDI (74.0 g, 456.4 mmol) in portions at 25 °C and the mixture was stirred at 25 °C for 2 h. To the resulted suspension was added l-(cyclopropylmethyl)piperazine dihydrochloride (4) (97.4 g, 457.0 mmol) in one portion at 25 °C and the mixture was stirred at 25 °C for 4 h. Water (1.0 L) was added in 2 h. The solid was filtered at 25 °C, washed with water and dried under vacuum at 65 °C to afford 1 (124.0 g) in 90 % isolated yield. LC-MS (C18 column eluting 90-10 CH3CN/water over 2 minutes) found (M+l) =451. 1H NMR (400 MHz, DMSO-76) d
10.40 (br.s, 1H), 9.11 (dd, 7 = 4.3, 1.6 Hz, 1H), 8.48 (dd, / = 8.4, 1.7 Hz, 1H), 8.40 (dt, /
7.4, 1.1 Hz, 1H), 8.25 (dd, 7 = 8.3, 1.3 Hz, 1H), 7.76 – 7.63 (m, 2H), 7.17 – 7.05 (m, 4H), 3.57 – 3.06 (m, 4H), 2.44 – 2.23 (m, 4H), 2.13 (d, J = 6.6 Hz, 2H), 0.79 – 0.72 (m, 1H), 0.45 – 0.34 (m, 2H), 0.07 – 0.01 (m, 2H) ppm.
[00174] Two impurities are also identified from this step of synthesis. The first impurity is Compound IM- 1 (about 0.11% area percent based on representative HPLC) with the following structure:
Compound IM-l)
Compound IM-l was generated due to the presence of N-methyl piperazine, an impurity in compound 2, and was carried along to react with compound 5. LC-MS found (M+l) =411.2;
(M-l)= 409.2. 1H NMR (400 MHz, DMSO-76) d 10.43 (brs, 1H) 9.13-9.12 (m, 1H), 8.52-8.50 (m, 1H), 8.43-8.41 (m, 1H), 8.26 (d, 7=4.0 Hz, 1 H), 7.73-7.70 (m, 2H), 7.15-7.097.69 (m, 4H), 3.60-3.25 (brs, 4H), 2.21 (brs, 4H), 2.13 (s, 3H).
[00175] The second impurity is Compound IM-2 (about 0.07% area percent based on the representative HPLC) with the following structure:
(Compound IM-2)
Compound IM-2 was due to the presence of piperazine, an impurity generated by
deprotection of compound 2. The piperazine residue was carried along to react with two molecules of compound 5 to give Compound IM-2. LC-MS found (M+l) =707. 1H NMR (400 MHz, CF3COOD) d 9.30-9.23 (m, 4H), 8.51 (s, 4H), 8.20-8.00 (m, 4H), 7.38-7.28 (m, 8H), 4.02-3.54 (m, 8H).
Solubility Experiments
[00176] Solubility measurements were done by gravimetric method in 20 different solvents at two temperatures (23 °C and 50 °C). About 20-30 mg of Form A, the synthesis of which is described below, was weighed and 0.75 mL solvent was added to form a slurry. The slurry was then stirred for two days at the specified temperature. The vial was centrifuged and the supernatant was collected for solubility measurement through gravimetric method. The saturated supernatant was transferred into pre- weighed 2 mL HPLC vials and weighed again (vial + liquid). The uncapped vial was then left on a 50 °C hot plate to slowly evaporate the solvent overnight. The vials were then left in the oven at 50 °C and under vacuum to remove the residual solvent so that only the dissolved solid remained. The vial was then weighed (vial + solid). From these three weights; vial, vial+liquid and vial+solid; the weight of dissolved solid and the solvent were calculated. Then using solvent density the solubility was calculated as mg solid/mL of solvent. Solubility data are summarized in Table 1.
Optimized Crystalline Form A Hemisulfate Salt Scale-up Procedure
[00202] An optimized preparation of Form A as a hemisulfate sesquihydrate salt with and without seeding is provided below.
Preparation of l-(cyclopropylmethyl)-4-(4-(quinoline-8-sulfonamido)benzoyl)piperazin- 1-ium sulfate trihydrate (Form A) with seeding
[00203] To a 2 L reactor under N2 was charged N-(4-(4-(cyclopropylmethyl)piperazine-l-carbonyl)phenyl)quinoline-8-sulfonamide (5) (111.0 g, 246.4 mmol), and a pre-mixed process solvent of ethanol (638.6 g), toluene (266.1 g) and water (159.6 g). The suspension was stirred and heated above 60°C to dissolve the solids, and then the resulting solution was cooled to 50°C. To the solution was added an aqueous solution of H2S04 (2.4 M, 14.1 mL, 33.8 mmol), followed by l-(cyclopropylmethyl)-4-(4-(quinoline-8-sulfonamido)benzoyl)piperazin-l-ium sulfate trihydrate (6) (1.1 g, 2.1 mmol). After 1 h stirring, to the suspension was added an aqueous solution of H2S04 (2.4 M, 42.3 mL, 101.5 mmol) over 5 h. The suspension was cooled to 22°C and stirred for 8 h. The solids were filtered at 22°C, washed with fresh process solvent (2 x 175 g) and dried to give the product (121.6 g) in 94% isolated yield. LC-MS (C18 column eluting 90-10 CH3CN/water over 2 minutes) found (M+l) = 451. 1H NMR (400 MHz, DMSO-76) d 10.45 (s, 1H), 9.11 (dd, J =
4.2, 1.7 Hz, 1H), 8.50 (dd, 7 = 8.4, 1.7 Hz, 1H), 8.41 (dd, 7 = 7.3, 1.5 Hz, 1H), 8.27 (dd, 7 8.2, 1.5 Hz, 1H), 7.79 – 7.60 (m, 2H), 7.17 (d, / = 8.4 Hz, 2H), 7.11 (d, J = 8.4 Hz, 2H), 3.44 (d, J = 8.9 Hz, 5H), 3.03 – 2.50 (m, 6H), 0.88 (p, J = 6.3 Hz, 1H), 0.50 (d, J = 7.6 Hz, 2H), 0.17 (d, 7 = 4.9 Hz, 2H).
Preparation of l-(cyclopropylmethyl)-4-(4-(quinoline-8-sulfonamido)benzoyl)piperazin- 1-ium sulfate trihydrate (Form A) without seeding
[00204] To a 50 L reactor was charged N-(4-(4-(cyclopropylmethyl)piperazine-l-carbonyl)phenyl)quinoline-8-sulfonamide (5) (1.20 kg, 2.66 mol) and water (23.23 L) at 28°C. While stirring the suspension, an aqueous solution of H2S04 (1.0 M, 261 g) was added dropwise over 2 h. The reaction was stirred at 25 – 30°C for 24 h. The solids were filtered and dried under vacuum below 30°C for 96 h to give the product (1.26 kg) in 90% isolated yield.
11. Reproduction and Preparation of Various Patterns
[00205] The patterns observed during the previous experiments were reproduced for characterization. Patterns B, D, E, F were reproducible. Pattern G was reproduced at lower crystallinity. Pattern I was reproduced, although, it was missing a few peaks. Refer to Table 20.
Crystalline Free Base Form of Compound 1
[00215] The crystalline free-base form of Compound 1 can be prepared via the following method.
[00216] 14.8 kg S-l and 120 kg DMAc are charged into a round bottom under N2 protection and the reaction is stirred at 30 °C under N2 protection for 40min, to obtain a clear yellow solution. 7.5 kg CDI (1.02 eq.) is added and the reaction is stirred at 30 °C for 2.5h under N2 protection. 0.6 kg of CDI (0.08 eq.) at 30 °C was added and the mixture was stirred at 30 °C for 2h under N2 protection. The reaction was tested again for material consumption. 11.0 kg (1.14 eq.) l-(cyclopropylmethyl)piperazine chloride was charged in the round bottom at 30 °C and the reaction was stirred under N2 protection for 6h (clear solution). 7.5 X H20 was added dropwise over 2h, some solid formed and the reaction was stirred for lh at 30 °C. 16.8 X H20 was added over 2.5h and the reaction was stirred stir for 2.5h. 3.8 kg (0.25 X) NaOH (30%, w / w, 0.6 eq.) was added and the reaction was stirred for 3h at 30 °C. The reaction was filtered and the wet cake was rinsed with H20 / DMAc=44 kg / 15 kg. 23.35 kg wet cake was obtained (KF: 4%). The sample was re-crystallized by adding 10.0 X DMAc and stirred for lh at 70 °C, clear solution; 4.7 X H20 was added over 2h at 70 °C and the reaction was stirred 2h at 70 °C; 12.8 X H20 was added dropwise over 3h and stirred for 2h at 70 °C; the reaction was adjusted to 30 °C over 5h and stirred for 2h at 30 °C; the reaction was filtered and the wet cake was rinsed with DMAc / H20=l5 kg / 29 kg and 150 kg H20. 19.2 kg wet cake was obtained. The material was recrystallized again as follows. To the wet cake was added 10.0 X DMAc and the reaction was stirred for lh at 70 °C, clear solution.
16.4 X H20 was added dropwise at 70 °C and the reaction was stirred for 2h at 70 °C. The reaction was adjusted to 30 °C over 5.5h and stirred for 2h at 30 °C. The reaction was centrifuged and 21.75 kg wet cake was obtained. The material was dried under vacuum at 70°C for 25h. 16.55 kg of the crystalline free base form of compound 1 was obtained. Purity of 99.6%.
C Kung. Activators of pyruvate kinase M2 and methods of treating disease. PCT Int. Appl. WO 2013056153 A1.
FG Salituro et al. Preparation of aroylpiperazines and related compounds as pyruvate kinase M2 modulators useful in treatment of cancer. U.S. Pat. Appl. US 20100331307 A1.
Route of administrationPO
FormulationTablet, unspecified
ClassAntianaemics, Piperazines, Quinolines, Small molecules, Sulfonamides
Mechanism of ActionPyruvate kinase stimulants
WHO ATC codeA16A-X (Various alimentary tract and metabolism products)B03 (Antianemic Preparations)B06A (Other Hematological Agents)
EPhMRA codeA16A (Other Alimentary Tract and Metabolism Products)B3 (Anti-Anaemic Preparations)B6 (All Other Haematological Agents)
Chemical nameN-[4-[4-(cyclopropylmethyl)piperazine-1-carbonyl]phenyl]quinoline-8-sulfonamide
Molecular formulaC24 H26 N4 O3 S
Agios Reports First Quarter 2017 Financial Results.
Agios Announces Initiation of Global Phase 3 Trial (ACTIVATE) of AG-348 in Adults with Pyruvate Kinase Deficiency Who Are Not Regularly Transfused.
A Phase 3, Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of AG-348 in Not Regularly Transfused Adult Subjects With Pyruvate Kinase Deficiency
ctiprofile
Agios Provides Business Update on Discovery Research Strategy and Pipeline, Progress on Clinical Programs, Commercial Launch Preparations and Reports First Quarter 2018 Financial Results at Investor Day.
An Open-Label Study To Evaluate the Efficacy and Safety of AG-348 in Regularly Transfused Adult Subjects With Pyruvate Kinase (PK) Deficiency
A Phase 2, Open-label, Multicenter Study to Determine the Efficacy, Safety, Pharmacokinetics, and Pharmacodynamics of AG-348 in Adult Subjects With Non-transfusion-dependent Thalassemia
Agios Announces Key Upcoming Milestones to Support Evolution to a Commercial Stage Biopharmaceutical Company in 2017.
Agios to Present Clinical and Preclinical Data at the 20th Congress of the European Hematology Association.
Agios Announces Updated Data from Fully Enrolled DRIVE PK Study Demonstrating AG-348s Potential as the First Disease-modifying Treatment for Patients with Pyruvate Kinase Deficiency.
Agios Announces New Data from AG-348 and AG-519 Demonstrating Potential for First Disease-modifying Treatment for Patients with PK Deficiency.
Agios Provides Update on PKR Program.
AG-348 Achieves Proof-of-Concept in Ongoing Phase 2 DRIVE-PK Study and Demonstrates Rapid and Sustained Hemoglobin Increases in Adults with Pyruvate Kinase Deficiency.
Agios Reports New, Final Data from Phase 1 Multiple Ascending Dose (MAD) Study in Healthy Volunteers for AG-348, an Investigational Medicine for Pyruvate Kinase (PK) Deficiency.
Grace RF, Layton DM, Galacteros F, Rose C, Barcellini W, Morton DH, et al. Results Update from the DRIVE PK Study: Effects of AG-348, a Pyruvate Kinase Activator, in Patients with Pyruvate Kinase Deficiency. ASH-Hem-2017 2017; abstr. 2194.
Available from: URL: https://ash.confex.com/ash/2017/webprogram/Paper102236.html
A Phase 2, Open Label, Randomized, Dose Ranging, Safety, Efficacy, Pharmacokinetic and Pharmacodynamic Study of AG-348 in Adult Patients With Pyruvate Kinase Deficiency
A Phase I, Open-label Study to Evaluate the Absorption, Distribution, Metabolism, and Excretion and to Assess the Absolute Bioavailability of AG-348 in Healthy Male Subjects Following Administration of a Single Oral Dose of [14C]AG-348 and Concomitant Single Intravenous Microdose of [13C6]AG-348
A Phase 1, Randomized, Open-Label, Two-Period Crossover Study Evaluating the Relative Bioavailability and Safety of the AG-348 Tablet and Capsule Formulations After Single-Dose Administration in Healthy Adults
A Phase 1, Single-Dose, Open-Label Study to Characterize and Compare the Pharmacokinetics, Safety, and Effect on QTc Interval of AG-348 in Healthy Subjects of Japanese Origin and Healthy Subjects of Non-Asian Origin
Agios Pharmaceuticals Initiates Multiple Ascending Dose Trial in Healthy Volunteers of AG-348 for the Potential Treatment of PK Deficiency, a Rare, Hemolytic Anemia.
A Phase 1, Randomized, Double-Blind, Placebo-Controlled, Multiple Ascending Dose, Safety, Pharmacokinetic, and Pharmacodynamic Study of Orally Administered AG-348 in Healthy Volunteers
Agios Initiates Phase 1 Study of AG-348, a First-in-class PKR Activator, for Pyruvate Kinase Deficiency.
A Phase I, Randomized, Double-Blind, Placebo-Controlled, Single Ascending Dose, Safety, Pharmacokinetic and Pharmacodynamic Study of Orally Administered AG-348 in Healthy Volunteers
Agios Pharmaceuticals Reports First Quarter 2014 Financial Results.
Agios Pharmaceuticals Reports Third Quarter 2013 Financial Results.
Agios Pharmaceuticals to Present Preclinical Research at the 2013 American Society of Hematology Annual Meeting.
Agios Presents Preclinical Data from Lead Programs at American Society of Hematology Annual Meeting.
Agios Pharmaceuticals Form 10-K, February 2018. Internet-Doc 2018;.
Available from: URL: https://www.sec.gov/Archives/edgar/data/1439222/000143922218000004/agio-123117x10k.htm
Agios Outlines Key 2018 Priorities Expanding Clinical and Research Programs to Drive Long Term Value.
Grace RF, Layton DM, Galacteros F, Rose C, Barcellini W, Morton DH, et al. Effects of Ag-348, a Pyruvate Kinase Activator, in Patients with Pyruvate Kinase Deficiency: Updated Results from the Drive Pk Study. EHA-2017 2017; abstr. S451.
Available from: URL: https://learningcenter.ehaweb.org/eha/2017/22nd/181738/rachael.f.grace.effects.of.ag-348.a.pyruvate.kinase.activator.in.patients.with.html?f=m3e1181l15534
Agios Presents Updated Data from DRIVE PK Study Demonstrating AG-348 is Well-Tolerated and Results in Clinically Relevant, Rapid and Sustained Hemoglobin Increases in Patients with Pyruvate Kinase Deficiency.
////////////MITAPIVAT, PHASE 3, Orphan Drug Status, Inborn error metabolic disorders, AGIOS
Drugs, Organic Chemistry, Fda
FLAGS AND HITS
Dentist Chandler, AZ eDirectories - World Wide Web Directory
Submit Tips Clear Free Directory | Free Article Web Directory
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redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Pagination with Controllers -> keeps redirecting to index.php I'm making a new thread on this, as I'm actually somewhere now.
I've got a paging system, but there's a problem.
I work with DAO's and controllers.
Thing is, my second page (of my paging system) goes to index.php?page=2. The major problem here is that whenever you go to a page that doesn't exist in the index.php it redirects automatically to index.php. Page 2 isn't mentioned there as I can't mention every single page there as the pages will increase the more items there will be inserted.
Here's the entire code I'm using for the paging: (edited)
<?php

    $mysqli = new mysqli("localhost", "wanthave", "wanthavepass", "wanthave");
    $count_mem = $mysqli->query("SELECT `id` FROM `wanthave_items`");
    $rows = $count_mem->num_rows;

    $perPage = 5; // items to be shown per page
    $num_pages = ceil($rows / $perPage);

    $visiblePages = 5; // if current page is 7 show: 5,6,7,8,9,...
    $visibleOffset = ceil($visiblePages / 2) - 1; // number of pages to show on the left and on the right of the current page

    // Where do you use this ???
    // $start = $page == 1 ? 0 : (($page - 1) * $perPage);

    if ($num_pages > 1) {

        $first = $last = $pagesStr = '';

            echo $first . $pageStr . $last;

        }
            foreach($items as $item) {
                echo "

                    {$item['name']}

";
            }

            for ($n = 1; $n < ($num_pages + 1); $n++) {
                echo "$n";
                if ($n < $num_pages) echo ", ";
            }
?>

my index.php
<?php
session_start();

define('DS', DIRECTORY_SEPARATOR);
define('WWW_ROOT', __DIR__ . DS);

$routes = array(
    'home' => array(
        'controller' => 'Item',
        'action' => 'index'
    ),
    'register' => array(
        'controller' => 'Users',
        'action' => 'register'
    ),
    'login' => array(
        'controller' => 'Users',
        'action' => 'login'
    ),
    'logout' => array(
        'controller' => 'Users',
        'action' => 'logout'
    ),
    'item-detail' => array(
        'controller' => 'Item',
        'action' => 'detail'
    ),
);

if(empty($_GET['page'])) {
    $_GET['page'] = 'home';
}
if(empty($routes[$_GET['page']])) {
    header('Location: index.php');
    exit();
}

$route = $routes[$_GET['page']];
$controllerName = $route['controller'] . 'Controller';

require_once WWW_ROOT . 'controller' . DS . $controllerName . ".php";

$controllerObj = new $controllerName();
$controllerObj->route = $route;
$controllerObj->filter();
$controllerObj->render();

A: This is quite a good post on simple pagination with PHP Limit pagination page number
With your example, for starter you should also validate that the page parameter is an integer and you can get partially rid of the very last if-else statement. So let's try optimizing the code a bit:
<?php

    $mysqli = new mysqli("localhost", "wanthave", "wanthavepass", "wanthave");
    $count_mem = $mysqli->query("SELECT `id` FROM `wanthave_items`");
    $rows = $count_mem->num_rows;

    $perPage = 5; // items to be shown per page
    $num_pages = ceil($rows / $perPage);

    $visiblePages = 5; // if current page is 7 show: 5,6,7,8,9,...
    $visibleOffset = ceil($visiblePages / 2) - 1; // number of pages to show on the left and on the right of the current page

    $page = isset($_REQUEST['page']) ? intval($_REQUEST['page']) : 1;

    // Where do you use this ???
    // $start = $page == 1 ? 0 : (($page - 1) * $perPage);

    if ($num_pages > 1) {

        $first = $last = $pagesStr = '';

        if($num_pages > $visiblePages){
            // no need to show First page if already on it
            if($page != 1){
                $first = "First";
            }

            // no need to show Last page if already on it
            if($page < $numPages){
                $last = "Last";
            }

            // the offset cannot be smaller or bigger than the min & max page number
            $fromPage = ($page - $visibleOffset) < 1 ? 1 : ($page - $visibleOffset);
            $toPage = ($page + $visibleOffset) > $numPage ? $numPage : ($page + $visibleOffset);
            for($i=$fromPage; $i<=$toPage; $i++){
                $pagesStr .= "$i";
            }

            echo $first . $pageStr . $last;

        } else {

            // NOTE: You don't really need this ELSE section at all

            // Where is $items defined ???
            foreach($items as $item) {
                echo "

                    {$item['name']}

";
            }

            for ($n = 1; $n < ($num_pages + 1); $n++) {
                echo "$n";
                if ($n < $num_pages) echo ", ";
            }
     }
}
?>

NOTE:
If you choose to remove the ELSE seciton, make sure to remove the
if($num_pages > $visiblePages){
    ...
}

part as well. It's one unnecessary check less since you can simply use the $fromPage and $toPage to cycle all available pages.
I haven't tried this code so there might be bugs in it, but the important thing is to not use hardcoded values anywhere in your code and to try and optimize the pagination process as much as possible (and there are few things that could be modified here).

redpajama_set_name: RedPajamaStackExchange


A reunited Bush played to a sold-out San Francisco crowd at Great American Music Hall on Tuesday night. Frontman Gavin Rossdale and original drummer Robin Goodridge were joined by Chris Traynor on lead guitar and Corey Britz on bass to promote Bush's new album, The Sea of Memories. The ever-charismatic Rossdale had the crowd in his pocket as the band tore through their new material as well as hits from their earlier albums Sixteen Stone and Razorblade Suitcase. Dead Sara opened the show impressively, with an energetic and emotion filled set that drew attention to the powerful team of singer Emily Armstrong and guitarist Siouxsie Medley.
Dead SaraCheck out even more badass photos HERE.


It seems Kelowna RCMP Const. Geoff Mantler is the victim of bad timing. Had he been caught on video kicking Buddy Tavares in the head during an arrest a couple of years ago, he might have been able to avoid suffering much more than a slap on the wrist.
But these days public confidence in police and especially the RCMP, is an all-time low. As a result, outrage at what Const. Mantler is alleged to have done has been pouring out and RCMP brass have moved surprisingly quickly to deal with the situation. Const. Mantler was immediately moved to administrative duties after the incident and was suspended -albeit with pay- a few days later. And it took only just over a week for outside investigators to recommend charges be brought against him – a few years ago the investigation could have quite possible dragged on for months. As I talked about in my latest Globe and Mail story on this case, the announcement came just before a rally protesting Const. Mantler's action was set to begin.
I expect crown prosecutors to make a decision on the charges sometime this week and Kelowna RCMP Supt. Bill McKinnon suggested Saturday that his superiors could decide to suspend Const. Mantler without pay some time this week as well.
Our top cops seem to have finally figured out that it hurts the reputation of all police when they protect officers who the public believes have done bad things. And that new found awareness likely means bad news for Const. Mantler.


text:
"Narcolepsy Goes to School" Program Educates Educators on Condition's Symptoms
Posted by Sleep Review Staff | Sep 23, 2014 | Narcolepsy, Prevailing Attitudes, Uncategorized | 0 |
By Karen Appold
Narcoleptic symptoms often begin in childhood or adolescence and can greatly disrupt every element of a child's educational experience, including academics, social development, and athletics.
Given this, Monica Gow—who co-founded Wake Up Narcolepsy (WUN) in 2008—felt a need to design a program specifically to bring awareness of the condition to the educational environment. Dubbed "Narcolepsy Goes to School (NGS)," the program aims to speed narcolepsy diagnosis and treatment by raising awareness among a high-risk, high-reward constituency.
"We frequently hear about insensitive if not abusive treatment of students with narcolepsy by peers and even teachers, indicating a vast gap in understanding the disease and empathy for narcoleptic students," says Gow, whose son began showing symptoms of narcolepsy at age 10.
"The disorder is poorly recognized and seriously underdiagnosed," continues Gow, who serves as executive director of WUN. "Educators, who spend extended periods of time with students, are often among the first people outside of the student's home to observe symptoms that may point to narcolepsy, but they can help these students only when they know the telltale symptoms."
Normally, excessive daytime sleepiness (EDS) presents itself most often when the student is inactive and is expected to concentrate, such as in class. "Teachers need to understand that sleepy students are probably just that, but the behavior could be a sign of a serious sleep disorder like narcolepsy," she says.
WUN offers on-site NGS workshops for teachers, school nurses, guidance counselors, coaches, and other educators. "We help school personnel recognize possible symptoms of narcolepsy," Gow says. "Then we work with the family to refer the student to a doctor, as only a specific medical test can make a proper diagnosis. We also offer recommendations for in-school accommodations that can be made to help the diagnosed student."
NGS also provides narcolepsy literature, and makes WUN staff available for helping educators address specific situations. All services and information are provided at no cost.
Specifically, the program asks school staff to help students with narcolepsy by practicing the "3 Rs of narcolepsy":
Recognize the symptoms of narcolepsy.
Respect that narcolepsy is a lifelong, serious sleep disorder that needs treatment.
Refer students who exhibit symptoms for a full medical diagnosis.
Often narcolepsy has a stigmatizing effect on students living with the disorder. "Teachers who know how to respond to EDS and cataplexy influence how fellow students and school staff respond to students with narcolepsy," Gow says. "Educators who respond to narcolepsy with calm and support will influence others to do the same. Respecting and encouraging students with narcolepsy inspires learning, maturity, and self-confidence.
"By expanding the understanding of narcolepsy among members of the school staff, our NGS program addresses the number one hurdle for speeding diagnosis and treatment—awareness," Gow concludes.
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text:
Prudential's Asian shares debut ahead of AIA merger vote
Image caption Prudential is looking to become an Asian insurance powerhouse
Prudential's shares fell on their debut on the Hong Kong and Singapore stock markets after they were caught up in a slide in global equity prices.
There are also concerns about Prudential's planned £24.6bn ($35.5bn) takeover of AIG's Asia arm, AIA.
Prudential wants to attract Asian investors for its £14.5bn rights issue, which will help fund the AIA deal.
But there is some opposition to the deal, as investors have questioned whether Prudential is paying too much.
'Comfortable'
Prudential chairman Harvey McGrath said he was confident of shareholder approval for the takeover.
"I think the vast majority are very comfortable with the transaction," said Mr McGrath, who was in Hong Kong for the share opening.
In Hong Kong, Prudential shares were slightly down from their opening price of $59.70 Hong Kong dollars at HK$58.90.
In Singapore, they were also down from the opening price of 7.72 Singapore dollars at SG$7.41.
Merger questions
I have other things that I need to spend my money on - like my children's education.
Slamet, Businessman, Batam island, Indonesia
Pru gambles on underinsured Asia
The insurer needs a 75% shareholder vote on 7 June to get the AIA deal approved.
While some investors believe AIA could be a good business, there are questions about whether Prudential is paying the right price.
There was further pressure on Tuesday with a report in the Financial Times saying that AIA's chief executive Mark Wilson planned to quit the business in the event of a takeover.
He was reported to have told colleagues that a joint Prudential-AIA business could not work.
'New Prudential'
Asian investors have until 4 June to decide whether they want to participate in the rights issue.
Prudential is keen to attract more Asian shareholders ahead of the 7 June meeting, because of the opposition already being voiced by some UK shareholders.
Prudential is currently the number two life insurer in Asia, following AIA, which has about 30 million customers in the region.
The combined firm "New Prudential" would be a dominant player in Asia, where the population is becoming wealthy enough to afford insurance.
Why Prudential gambles on Asian growth
Prudential gives details of £14.5bn rights issue
Prudential delays $21bn rights issue to buy AIA
Tidjane Thiam: The man from the 'Pru'
Prudential Corporate
Prudential Action Group


text:
No Matter How You Vote, The New Congress Won't Represent You
Authored by Ryan McMaken via The Mises Institute,
Advocates for the political status quo flog this position repeatedly, claiming that taxation and the regulatory state are all morally legitimate because the voters are "represented." Even conservatives, who often claim to be for "small government" often oppose radicalism of any kind — such as secession — on the grounds that political resistance movements such as the American Revolution are only acceptable when there is "taxation without representation."The implication being that since the United States holds elections every now and then, no political action outside of voting — and maybe a little sign waving — is allowed.
This, position, however, rests on the idea that elected officials are truly representative. If taxation with representation makes government legitimate - as some argue - then we must first establish that the government's claims of representation are believable.
To conclude therefore, that any specific voter has consented to, say, a tax increase because his "representative" approved it, is an extremely sketchy endeavor, at best.
Two Ways Representation Doesn't Work
Specifically, there are two ways that real-world political representation doesn't fit the population notions of how it all works.
First of all, even if a politicians wanted to faithfully represent the people within his constituency, this would be impossible. It is impossible because the politicians can't know the views of the whole population of his constituency. And it's impossible because the more diverse a constituency becomes, the more unlikely it is that any legislation can be crafted to serve the interests of all members of the constituency equally.
The Impossibility of Representing "the People"
Casey illustrates that even at a very basic level, political representation does not work on a theoretical level. But let us be "practical" types for a few minutes and imagine that we could, in theory, put together a constituency of people with similar economic, cultural, and religious interests. We could then at least entertain the idea that it might be possible to represent this group. That is, with a constituency that is highly homogeneous, we could at least make a claim that we can understand and pursue the interests of the group.
Large states ... will encompass more political interests than small states, all other things being equal. ... [A]lthough small population does not guarantee homogeneity, large population does result in heterogeneity.
[A]n expanding constituency size is not an insubstantial contribution to House members' level of ideological divergence from their constituents. ... In smaller, ideologically cohesive constituencies it is easier for legislators to satisfy the policy desires of the citizenry. The growth in House district populations seems to have increased the distance between the representative and constituents of the area of policy representations.
Consequently, it's not surprising that once we get to the level of the US Senate, representatives show virtually no congruence with the ideologies of the people they're supposed to represent. In his empirical study of representation, Michael Barber writes :
Naturally, this can be affected by factors other then mere heterogeneity of the population — such as the need to cultivate relationship with those who can provide campaign funds. Nevertheless, the impossibility of representing the interests of such a large population drives a legislator to pick and choose whose interests he decides to listen to. In the case of the Senate, Barber finds those who do get represented are often the constituents "who write checks and attend fundraisers."
But it's not necessary to conclude that legislators listen to wealthy donors for cynical reasons. Even if a Senator under these circumstances wanted to represent all five million of his constituents (as would be the case in a medium-sized state like Minnesota or Colorado) It's important to reiterate that this is simply an impossible task under the delegate model of representation.
Up to this point, we've been assuming that elected officials imagine themselves largely as delegates of the populations they represent. This, after all, is the assumption behind the basic framework of Madisonian political theory: that different socioeconomic and cultural groups will be represented in Congress by elected officials, and these different groups will pursue their own interests, thus providing checks and balances against each other.
But what if elected officials don't view themselves this way?
What if they view themselves as trustees whose job it is to do what's "best" for the people in their district regardless of what the voter preferences actually are?
Those who have worked with elected officials will see little novelty in this suggestion. If I may be permitted a personal anecdote, I will note that in my days working with state legislators, it was not uncommon to be told by a legislator that he or she was torn as to whether vote in a way "the voters want" or to do "the right thing." The "right" thing, in the mind of a legislator, is simply that which comports to his or her personal ideology.
If the legislator chose to overrule what he or she perceived to be the opinion of "the people," then at least onthat day, the legislator was acting as a trustee rather than as a delegate.
There is, of course, no such thing as a "district opinion," but the general idea is clear enough: when confronted with how to vote on an issue, a legislator, at least in Matsusake's study, usually votes according to his own ideological views — even when he suspects a majority of his own voters prefer otherwise.
While its certainly possible to defend legislators who vote according to personal principal on various grounds, we cannot also claim that this sort of governance is a "representative" system in line with popular notions of how political representation is equivalent to voter consent for various political agendas.
If elected officials are in the habit of voting to suit their own ideologies — even when it means overriding the ideological preferences of many voters — then its hard to see how we can also call this "representative" or a system that transmits "consent" from the voters to their political representatives.
And yet, in spite of all the evidence that elected officials neither know the preference of voters, nor vote in accordance with them, we continue to be told that governments must be respected and obeyed because they have legitimacy granted to them by the fact they are "democratic" and "representative."
For centuries, this myth of representation has served to quash opposition to government abuse, and to claim that submission to government is 'voluntary'... It's time to abandon the myths.


Policies supporting healthy food access and proper nutrition are an integral part in the fight against obesity. Below is a menu of nutrition policies, sample language from cities that have passed policies and additional resources such as model language and factsheets to support the passage of these policies.
Nutrition Standards increase the availability of healthy food and beverages in municipal facilities, programs and events. Specific policies include vending machine standards and contracts, healthy meeting policies, standards for food and beverages served in childcare and afterschool programs. El Monte, CA: Requires 100% healthy items in city facilities California Center for Public Health Advocacy's "Model Nutrition Standards for Vending, Snacks, Beverages and Meals"
Farmers Markets bring fruits and vegetables to residents. Specific policies include defining farmers' markets in the comprehensive plan and zoning code, allowing markets on city owned properties, minimizing permit fees, encouraging them to accept the electronic benefit transfer card (EBT) and WIC coupons.
Community Gardens provide produce to residents, neighborhood green space, places for physical activity and opportunities for community building. Specific policies include defining community gardens in the comprehensive plan and zoning code and allowing gardens on city owned properties and discounting permitting fees. Chula Vista: uses vacant city property for community gardens Local Government Commission's "Cultivating Community Gardens: The Role of Government in Cultivating Healthy, Livable Neighborhoods"
Urban Agriculture encompasses the cultivation, production, processing, sale and distribution of produce, bees, poultry and small livestock in urban areas. Urban agriculture encompasses home gardens and urban farms as well as community gardens. San Diego: Robust Urban Agriculture and Community Gardens policies. Included are both the policy language and a summary table of the ordinance ChangeLab Solutions' "Seeding the City: Land Use Policies to Promote Urban Agriculture"
Mobile Produce Stands bring healthy food to underserved neighborhoods. Specific policies include defining mobile produce markets in the comprehensive plan and zoning code, allowing markets on city owned properties and minimizing permit fees. New York City: increases permits for produce carts in neighborhoods with limited access to fruits and vegetables ChangeLab Solutions' "Model Produce Cart Ordinance"
Grocery store attraction requires a complex set of policies and incentives grounded in partnerships among municipalities, community residents, developers, financiers. Specific municipal policies include comprehensive plan policies to ensure standards for access to healthy retail, loan standards, zoning language to facilitate land assembly and uses, expedited permitting processes. Los Angeles: healthy market opportunity initiative to support healthy grocery and restaurants PolicyLink's "Grocery Store Attraction Strategies: A Resource Guide for Community Activities and Local Governments"
Limits on Drive-Thru and Fast Food Restaurants allow cities to maintain a balance between chain restaurants and locally owned establishments, and to promote a balance between retailers of produce and healthy staple items, and retailers of fast food. Specific policies include zoning, moratoriums and conditional use permits.


text:
En la mitología griega, Neso es el nombre de varios personajes:

 Neso, centauro, hijo de Ixión y Néfele, una ninfa-nube a la que Zeus había dado la forma de Hera.
 Neso, un oceánida (dios-río), hijo de Océano y Tetis.
 Neso, un troyano muerto por Áyax el Grande.
 Neso, una de las nereidas, hijas de Nereo y de Doris, que no debe confundirse con su hermana Nesea.
 Neso, una hija del troyano Teucro que fue una de las esposas de Dárdano y madre de Sibila.

Astronomía

 Neso, satélite irregular de Neptuno.

Zoología
 Neso, un género de escarabajos de la familia Scarabaeidae.

Referencias

redpajama_set_name: RedPajamaWikipedia


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text:
Three Tips for Timing International Attendee Marketing Campaigns
by Anjia Nicolaidis
Determining when to launch an international marketing effort requires careful consideration of multiple variables, including event frequency and location, industry budgeting practices, visa and other travel requirements, as well as the competitive landscape. mdg's International Marketing Specialist Anjia Nicolaidis shares three pieces of advice for evaluating these data points and timing international campaigns around a prospective visitor's journey.
Build Ample Time for Awareness
To ensure international prospects are planning and budgeting for an event, they must be made aware of it well in advance. It's important to note that while the fiscal year in most international markets runs from January to December, there are many exceptions. For example, Australia's fiscal year runs from July to June and India's from April to March. Regardless, we find that most international professionals plan their trade show participation a full nine to 12 months in advance. International visitors are also considering travel options around trade events long before they actually register. Many plan ancillary business or personal travel in an effort to maximize the the trip's ROI.
With this in mind, mdg typically begins brand awareness activities a year in advance of an event (particularly if the event is new and/or if the prospects are cold) with interest-building messaging kicking in nine months in advance.
Share Program Content Six Months Out
Most organizers will start to see an uptick in conversions to registration at six months out from the event, assuming they are effectively communicating the value proposition of the event to prospects. As such, this is when campaign activities should move from building awareness and interest to creating engagement and prompting action. This means placing more emphasis on high-value content, including keynote speakers; matchmaking programs; networking events; innovations that will be featured on the expo floor; industry influencers who will be participating; and more.
Also, once prospective visitors have registered to attend, they may need to apply for a U.S. visa, depending on their country of residence. According to the U.S. Department of State, getting a visa appointment can take anywhere from a few days to three weeks based on the volume of visa applicants and the embassy's available resources. Despite this, most U.S. embassies will advise visa applicants to apply at least three months before their planned travel date. Some visa applications require additional screening due to tighter controls of visa clearances; this can mean waiting another 60 days to receive notification of approval or denial. As marketers, we have to factor this into how we time our campaigns, especially in markets like China or India.
Prioritize Leads in the Final Push for Registrations
Marketing and messaging across all domestic and international segments in the final three months tend to focus almost exclusively on conversion. This is when we prioritize the leads in our funnel that have shown higher levels of engagement (they've attended in the past, visited the website, clicked on ads, watched videos, and/or otherwise interacted with our communications). This is also when we shift marketing efforts away from the most distant countries and/or those that have rigorous visa/travel restrictions and focus on the countries in closer proximity to our events. Finally, we compare how we're tracking on a country-by-country basis with previous editions of our event to determine if there are any "last-minute" course corrections we need to make to try to close existing gaps.
Following these three guidelines will go a long way toward overcoming the unique obstacles that can occur when targeting an international audience and increasing the ROI on your international marketing efforts.
A version of this content originally appeared in PCMA Convene October 2018
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Make Steel Cut Oats in your Instant Pot!
Fast and easy breakfasts are a must on a busy morning, and if it's healthy and can keep you satisfied for hours… it's a win win! These Instant Pot Steel Cut Oats are all the things: fast, easy, healthy and the best part is that they keep you feeling full longer than other breakfast options. The best part is that you can make it ahead and keep it in the fridge for a few days or in the freezer for a few months until you are ready to eat them.
There are a few benefits of steel cut oats vs. regular oats, for starters, they hold their shape better when cooked and they don't get mushy like regular rolled oats. They also take longer for your body to digest so you stay full longer. They also freeze great once cooked, making this breakfast easy on a busy morning…just warm it up in the microwave for a few minutes with a little milk or water.
If you are into meal prepping, this is a great breakfast to meal prep. They can be stored in the fridge for the week ahead or if you choose to freeze them, they will keep in the freezer for up to 3 months. You can freeze them in a muffin tin. Just lightly spray the muffin tin with non stick spray. Add about 1/2 cup portion to each and freeze. Once frozen solid (about 2 hours in the freezer), you can let it thaw for a few minutes at room temp and spin the oatmeal portion around inside it's container until it will gently release. Move frozen pre-portioned oatmeal cups to a ziplock freezer bag to store in the freezer. When ready to eat, just warm it up in the microwave for 1-2 minutes depending on your microwave. Add a splash of milk or water to help loosen it up and cool it down if needed.
This steel cut oats basic recipe is the same, but we have topped them a few different ways, and then frozen them with the toppings for more ease in the morning.
Cook Steel Cut Oats in your Instant Pot pressure cooker and enjoy them in less time with less mess. These little pre portioned cooked oats make meal planning breakfast super easy, store in the fridge to enjoy during the week ahead or freeze them up to 3 months.
In the inner stainless steel pot of the Instant Pot Pressure Cooker add the steel cut oats, water, cinnamon and vanilla. Stir to combine.
Place the lid on with the pressure release valve pointing to the sealed position.
Cook on high pressure for 4 minutes. Your instant pot will take a few minutes to come to pressure before the 4 minutes will start to count down. After the 4 minutes, let your Instant Pot do a natural release of steam for 10 minutes.
Gently remove the lid and stir in the maple syrup for sweetness. Top with fresh fruit, nuts and seeds. Serve with more maple syrup and milk. Enjoy!
If freezing the cooked oats, lightly spray a muffin tin and scoop 1/2 cup portions of the cooked oats and place into each spot in the muffin tin. Freeze for 2+ hours until solid. Gently release each one from the muffin tin by letting them sit at room temp for a few minutes before releasing each one. Store in a freezer storage bag up to 3 months.
Do not do a quick release when cooking steel cut oats in a pressure cooker, the valve will get all gunked up with the oats.
If you are ready to get back to a routine with the new school year, this would be a great way to start your days off right!
I'd love to know, do you have a favorite way to top oatmeal? I'd love to hear! With peaches in season, peaches and cream is the BEST right now!


Good luck with the yarn diet! And yes, The croft is such a dreamy yarn to work with!!!!
I already have a project picked out, just waiting for the stock!
Well done! I love a good destash!
Thank you 🙂 I think it was about time! Now I just hope I can keep it up!


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