Pricing of orphan drugs in oncology and rare diseases

Objective: The objective of this paper is to determine an upper price limit for an orphan drug by taken a broader perspective and, including also other monetary and non-monetary values for the society. Methods: This model is based on the expected free cash flows and the required minimum rate of return for the investor. In addition we calculated an innovation premium resulting from cost savings due to the substitution effect and the monetary gain in QALYs of a new medicine. We selected Spinraza®, a first in class drug with only best supportive care as comparator, and Perjeta®, a first in class drug with already an actual treatment as comparator. Results: The results show that Spinraza® leads to an innovation premium of € 78,966 and Perjeta® shows an innovation premium of € 4,388, because there were no cost savings. The analyses show the outcomes are sensitive to discount rate for QALYs. Conclusion: The break-even price from only an investor perspective may not reflect the value of drug from a broader perspective. This study shows drug prices based on an innovation premium may be more representative of the actual value of innovation for the society.

Psychological Distress Among Orphaned Youth and Youth Reporting Sexual Exploitation in Kampala, Uganda

Psychological distress is a priority health issue in low- and middle-income countries; however, it is inadequately addressed among vulnerable youth living in extremely underserved communities (i.e., on the streets and in the slums) who are at a high risk of experiencing adversity. The purpose of this study was to compute the prevalence of self-reported psychological distress among youth living in the slums of Kampala, Uganda, and examine how orphan status and commercial sexual exploitation (CSE) are related to youth psychological distress. Analyses are based on a 2014 cross-sectional survey of service-seeking youth (N = 1134) in Kampala, Uganda. Bivariate and multivariable multinomial regression analyses were used to determine associations between orphan status, sexual exploitation, and psychological distress (defined as experiencing the following proxy variables for more complex psychopathology: hopelessness and/or worry). Among all youth participants, 83.2% (n = 937) reported at least one type of psychological distress; 51.3% (n = 578) reported experiencing both types. The reported prevalence of any type of psychological distress was highest among youth who reported experiencing sexual exploitation (91.2%), double orphans (90.0%), and single orphans (83.8%); however, a high prevalence (76.7%) of any type of distress was also found among youth who reported both parents alive. Experiencing both types of distress was associated with being a double orphan (adjusted odds ratio [AOR] = 2.92, 95% confidence interval [CI] = [1.77, 4.81]), reporting CSE (AOR = 2.71, 95% CI = [1.67, 4.41]), and increased age (AOR = 1.31, 95% CI = [1.20, 1.44]). Psychological distress is prevalent among all youth living in the slums of Kampala and is independently associated with being a double orphan and experiencing CSE. These findings underscore the urgent need to intervene with all youth who reside in this particular underserved community, especially those who have lost both parents, and to prevent CSE among this vulnerable, underserved population.

Epidemiology of Atypical Hemolytic Uremic Syndrome: A Systematic Literature Review

Atypical hemolytic uremic syndrome (aHUS) is a rare but severe disorder that frequently has a genetic component and results from the overactivation of the alternative complement pathway. As research moves toward improved diagnosis and therapy of aHUS, it will be important to better understand its epidemiology. Our objective was to conduct a systematic literature review to assess the incidence and prevalence estimates of aHUS globally. A comprehensive literature search was conducted in Embase and MEDLINE. Additionally, practice guidelines, databases of national/international organizations, and regulatory agencies were searched. From 2960 publications identified via MEDLINE and Embase, 105 publications were eligible for full-text screening, and a total of eight full-text articles met eligibility criteria for inclusion. Regional epidemiologic estimates were obtained for Europe and Oceania. Country-specific data were available for France, Norway, Australia, and Italy. Four of the identified studies reported on the prevalence of aHUS, prevalence in the age group of 20 years or younger was ranging from 2.2 to 9.4 per million population, while the only study that reported prevalence in all ages showed a prevalence of 4.9 per million population. Six studies reported on the incidence of aHUS, annual incidence in the age group of 20 years or younger was ranging from 0.26 to 0.75 per million population, and for all ages, annual incidence was ranging from 0.23 to 1.9 per million population. To our knowledge, this is the first systematic review conducted to provide a comprehensive overview of global incidence and prevalence estimates of aHUS. In general, incidence estimates were similar across all the studies; however, prevalence data were found to be more variable. Study limitations were related to inconsistencies in the definitions of aHUS between studies and also a dearth of epidemiological studies assessing incidence and prevalence of aHUS outside of Europe.

Charles Scott Sherrington's origins

James Norton Sherrington who is normally described as the father of Charles Scott Sherrington, winner of the 1932 Nobel Prize for Medicine, died at least eight years before Charles was born. The article discusses whether Charles was born in India of unknown parents or was the illegitimate child of Caleb Rose and Anne Sherrington.

Strongylid infection varies with age, sex, movement and social factors in wild African elephants

Comparing parasitic infection among individuals of wildlife populations can provide insight into factors that influence wildlife disease ecology. Strongylids are parasitic worms that infect the intestinal tract of vertebrates, and infection with strongylids can be approximated by counting strongylid eggs in dung samples. Here we tested for correlations between strongylid egg counts and 18 different individual characteristics, environmental and social factors in individually known wild African elephants. We counted more eggs in the dung samples of younger elephants and females relative to mature elephants and males. We also found that elephants spending more time outside reserves shed more strongylid eggs than elephants that were more often within reserves. Elephants that were less socially integrated, as measured by how much aggression they received from other elephants, shed fewer strongylid eggs; relatedly, socially isolated orphan elephants that had left their family shed fewer strongylid eggs than elephants that remained with their family. Our results suggest that landscapes altered by livestock grazing and social disruption caused by humans may impact parasitic infection in wildlife.

Reimbursement Status and Recommendations Related to Orphan Drugs in European Countries

Objective: To review the reimbursement recommendations issued by selected European health technology assessment agencies for orphan drugs and the reimbursement status of these drugs; to assess the relationship between the type of recommendation and reimbursement status.

Methods: The list of orphan drugs to be included in the analysis was obtained from the European Medicines Agency and Orphanet. Seven European states were included in the analysis: Belgium, England, France, Germany, Poland, Scotland, and Spain. For all identified orphan drugs, relevant data on the reimbursement status and type of recommendation were collected for each country. The relationship between the type of recommendation and reimbursement status was evaluated separately for each considered country, using Cohen’s kappa coefficient for the measurement of agreement; sub-analyses for oncology and metabolic drugs were performed.

Results: Most reimbursement recommendations for orphan drugs were positive (71%), while approximately 17% were negative and almost 13% were conditional. The highest percentage of positive reimbursement recommendations was observed in Spain (97%) and France (95%) and the highest percentage of negative reimbursement recommendations was revealed for Poland (49%). On average, 65% of the 163 analyzed orphan drugs were reimbursed from public funds. The highest number of reimbursed orphan drugs was observed in Germany (n = 148), while the lowest, in Poland (n = 41). Considering all analyzed drugs, the highest agreement between recommendations and reimbursement status was observed for Spain (value of 1), and the lowest, for Germany (κ = -0.03).

Conclusions: On average, more than 60% of identified orphan drugs were reimbursed from public funds in the included countries, and the majority of reimbursement recommendations were found to be positive. The agreement between reimbursement recommendations and reimbursement status differed between the countries, but overall, it did not show any patterns, as it ranged from -0.03 to 1 (κ coefficient).

Orphan Medicines for Pediatric Use: A Focus on the European Union

PURPOSE

European policy makers have provided a number of incentives for the development of medicines for orphan diseases as early as 1999 through the Orphan Regulation and created obligations for medicines developers to investigate their products in children through the Paediatric Regulation adopted in 2006. This article describes the challenges that developers of orphan medicines are facing with pediatric indications, discusses the interplay between the Orphan Regulation and the Paediatric Regulation, and provides some recommendations on how to optimize drug development under the current European Union regulatory framework.

METHODS

This article discusses the European Union's Orphan Regulation, Paediatric Regulation, and the implications of the intersection of the regulations on the development of orphan medicines for pediatric use.

FINDINGS

Although these regulations have been successful in meeting their objectives separately, different regulatory frameworks entail separate governance, multiple assessments, varying approaches and priorities to unmet medical needs, and joined-up regulatory process coordination. Better integration of regulatory pathways would therefore be helpful in stimulating more global drug development of pediatric orphan medicines, including optimizing the interaction between both regulations, using innovative drug development approaches while considering alternatives to randomized clinical trials, better identification and prioritization of unmet medical needs in pediatrics, and ensuring the alignment of regulatory processes.

IMPLICATIONS

Rare diseases are categorized as "orphan diseases" because their occurrence in a small number of patients means that, regardless of the apparent high unmet medical need, there is limited public and market interest to justify the high development risk and significant investment to develop new treatments. However, unexplored potential within the area, as well as a conducive regulatory environment, can further support the development of medicines to treat rare diseases, including for children.

Prevalence of pulmonary arterial hypertension in the Colombian Caribbean

In Latin America, there are no specific data on the prevalence of pulmonary arterial hypertension (PAH). For this reason, the Registro Latinoamericano de Hipertensión Pulmonar (RELAHP) is under development. The aim of this study is to estimate the prevalence of PAH in the Colombian Caribbean in 2015 based on data from a private health insurance company (PHIC) with coverage in that region. All the Individual Service Delivery Registries (RIPS) of all ambulatory care centers that serve the population of the Colombian Caribbean region affiliated with a PHIC selected for this research were reviewed. All patients who had a diagnosis of pulmonary hypertension (PH) were included (International Classification Diseases 10-Revision [ICD-10 I270, I272, I278, and I279]). Subsequently, the information on electronic medical records was reviewed. To estimate the prevalence of PAH, the total population of the PHIC and population projections of Colombian Caribbean by Departamento Administrativo Nacional de Estadisticas (DANE) was used. We identified 27 patients with a confirmed diagnosis of PH and 18 patients with a confirmed diagnosis of PAH. Taking into account the total population affiliated to the Caribbean Regional of the PHIC selected for the study in September 2015, a PAH prevalence of approximately 28 cases per million inhabitants is estimated. The mean of age was 22 ± 21.4 years (14.8% children) and 17 (62.9%) were girls/women. The majority of patients presented with PAH (Group 1) (66.6%). The estimated number of cases of PH in Colombian Caribbean in 2015 is approximately 292 cases or 1 in 35,760. Epidemiological estimates of PAH in the Colombian Caribbean are compatible with the definition of orphan or rare diseases. The majority of patients are female.

Divorce, living arrangements, and material well-being during the transition to adulthood in rural Malawi

In this paper, we use longitudinal data to investigate how parental death and divorce influence young women's own experience of divorce in Malawi, a setting where women marry relatively early and unions are fragile. We find that maternal death and parental divorce are positively associated with divorce for young women but, after controlling for socio-demographic and marital characteristics, only the association with maternal death remains statistically significant. Maternal and paternal death are both strongly associated with women's post-divorce living arrangements, which in turn affects their material well-being. This finding suggests that divorcing at a young age shapes the subsequent life chances of women; although some women return to their parental home and may have the opportunity to reset the transition to adulthood, other women begin their 20s as head of their own household and with considerable material disadvantage.

QQS orphan gene and its interactor NF-YC4 reduce susceptibility to pathogens and pests

Enhancing the nutritional quality and disease resistance of crops without sacrificing productivity is a key issue for developing varieties that are valuable to farmers and for simultaneously improving food security and sustainability. Expression of the Arabidopsis thaliana species-specific AtQQS (Qua-Quine Starch) orphan gene or its interactor, NF-YC4 (Nuclear Factor Y, subunit C4), has been shown to increase levels of leaf/seed protein without affecting the growth and yield of agronomic species. Here, we demonstrate that overexpression of AtQQS and NF-YC4 in Arabidopsis and soybean enhances resistance/reduces susceptibility to viruses, bacteria, fungi, aphids and soybean cyst nematodes. A series of Arabidopsis mutants in starch metabolism were used to explore the relationships between QQS expression, carbon and nitrogen partitioning, and defense. The enhanced basal defenses mediated by QQS were independent of changes in protein/carbohydrate composition of the plants. We demonstrate that either AtQQS or NF-YC4 overexpression in Arabidopsis and in soybean reduces susceptibility of these plants to pathogens/pests. Transgenic soybean lines overexpressing NF-YC4 produce seeds with increased protein while maintaining healthy growth. Pull-down studies reveal that QQS interacts with human NF-YC, as well as with Arabidopsis NF-YC4, and indicate two QQS binding sites near the NF-YC-histone-binding domain. A new model for QQS interaction with NF-YC is speculated. Our findings illustrate the potential of QQS and NF-YC4 to increase protein and improve defensive traits in crops, overcoming the normal growth-defense trade-offs.

Effects of Institutionalization and Parental Living Status on Children's Self-Esteem, and Externalizing and Internalizing Problems in Rwanda

The negative effects of institutionalization on children's wellbeing and psychological adjustment have been extensively documented. Throughout the world, particularly in developing countries, many children in residential child care institutions known as orphanages have parents, and it is not clear how this situation affects the psychological adjustment of institutionalized children. This study aimed at investigating specifically whether institutionalization impacts negatively children's psychological adjustment defined in terms of externalizing and internalizing behavior problems and self-esteem and whether having living parents or not has an additional influence. Children were recruited in Rwanda from seven registered institutions and six primary schools. Ninety-six institutionalized children (48 orphans, who lost at least one parent, and 46 non-orphans, who had both parents living) and 84 non-institutionalized children, who lived in a family (28 orphans and 56 non-orphans) aged 9 to 16 participated. The caregivers or parents assessed externalizing and internalizing behavior problems using the Child Behavior Checklist. Children completed the Coopersmith Self-Esteem Inventory. Controlling for gender, age, and residential area, analyses of covariance revealed that institutionalized children had significantly more externalizing behavior problems than had non-institutionalized children. In addition, non-orphans had more externalizing behavior problems than had orphans, regardless of whether they lived in an institution or not. There were no group differences in internalizing behavior problems, but there was a significant main effect of the parental living status (orphans vs. non-orphans) and a significant interaction effect between parental living status and institutionalization on self-esteem. Self-esteem of non-orphans in families was significantly higher than self-esteem of the other groups. This should be considered when making the decision to place a child in an institution, especially when her or his parents are still living, and when developing supportive programs for children without adequate parental care.

Rare ophthalmology diseases

Rare ocular pathology has an important impact on the quality of life of patients because often the damage is bilateral and, although asymmetric, causes a significant decrease in visual acuity. Because it may be asymptomatic until a relatively late stage, diagnosis is frequently delayed. A general understanding of the disease pathophysiology, diagnosis, and treatment may assist primary care physicians in referring high-risk patients for comprehensive ophthalmological examination and for a more active involvement in their care. Moreover, a significant percentage of these orphan diseases do not have treatment approved by the FDA. The examination and monitoring of patients with rare ophthalmological disorders represents a key component of an ongoing project at the University Emergency Hospital, Bucharest, Romania - Ophthalmology Clinic. Rare disease registries are leading tools for the development of clinical research for rare diseases, improvement of patient access to new diagnostic methods, follow-up and new emerging therapies. As of this moment, the European list of rare diseases includes 53 ophthalmological diseases, which are classified as rare diseases and another 103 systemic diseases with ophthalmological involvement, out of a total of 7000 rare diseases.

Highly Innovative Drug Program in the Czech Republic: Description and Pharmacoeconomic Results-Cost-Effectiveness and Budget Impact Analyses

BACKGROUND

Highly innovative drugs (HIDs) can be granted 2 to 3 years of temporary reimbursement (TR) to provide timely patient access and to collect real-world evidence through registries in the Czech Republic. A TR applicant does not need to comply with cost-effectiveness (CE) requirements and the willingness-to-pay threshold. It is only when mandatory transition to permanent reimbursement (PR) status occurs does the drug need to comply with CE and willingness-to-pay requirements.

OBJECTIVES

To describe and evaluate the HID program in the Czech Republic by analyzing the pharmacoeconomic results when a drug starts with TR status and transitions to PR status.

METHODS

The study was a retrospective analysis of reimbursement decisions of HIDs. All drugs approved for TR (valid from January 2008 to January 2018) were identified. A description of the HIDs and their pharmacoeconomic results were analyzed.

RESULTS

Fifty TR drugs were identified. Most (68%) were oncology drugs and 44% were orphan drugs. After the expiration of their TR status, 83% were successfully transitioned to PR status. Cost-utility analysis was used to support CE results in 42% of the TR drugs. The mean incremental cost-effectiveness ratio (cost/quality-adjusted life-year) of drugs that entered TR status was €97,868. When the time came for transition to PR status, the mean incremental cost-effectiveness ratio was €34,086 (lower by 65%). Net budget impact increased by 3% and decreased by 25% in the first and fifth years, respectively, after applying for PR.

CONCLUSIONS

This analysis provides better insight into the HID program for costly innovative drugs over a 10-year follow-up. A successful transition to PR status was observed for most of the HIDs (83%).

Mental health among adolescents living with HIV in Namibia: the role of poverty, orphanhood and social support

The mental health needs of children and adolescents living with HIV (ALHIV) in Namibia are poorly understood, despite the dramatic improvement in their survival. ALHIV in resource poor contexts face particular risk factors, such as poverty, orphanhood, and poor social support. This study examines the mental health of ALHIV in Namibia, and the factors that contribute to mental health problems. A case-control design assessed emotional and behavioural symptoms of distress, risk and protective factors among adolescents aged 12-18 years. Case participants were 99 HIV-positive adolescents. Case controls were 159 adolescents from the same community who were not known to be HIV seropositive at the time of the study. Control group participants were selected from schools using a stratified random sampling. A larger proportion of HIV-positive adolescents were orphaned (62.6% vs. 20.8%, p < .001); the groups showed no differences in poverty factors. HIV-positive adolescents scored lower than the control group on total perceived social support (p < .05) and caregiver support (p < .05), but no differences in perceived friend support and support from a self-selected person were present. HIV-positive adolescents reported significantly more total emotional and behavioural difficulties (p = .027) and conduct problems (p = .025), even after controlling for socio-demographic factors. However, after controlling for the effects of orphanhood, group differences in mental health outcomes were no longer significant. Furthermore, mediation analysis suggested that social support completely mediated the relationship between HIV status and mental health (standardised pathway coefficients = .05, p = .021). Policies and programmes that aim to strengthen social support and take orphanhood status into consideration may improve the mental health of adolescents living with HIV.

How to prevent the next Marathon Pharmaceuticals

In recent years, several drug companies have exploited U.S. regulatory policies to acquire exclusive rights to cheap therapies and substantially raise their prices, and Federal agencies and state governments are exploring various ways to prevent or punish such behavior in the future. Among these cases, however, Marathon Pharmaceuticals’ handling of Emflaza (deflazacort) is unique, because the drug was previously only available abroad, and was never previously sold in the U.S. before the company obtained FDA approval for it. Thus, laws and policies designed to address price hikes on already-marketed drugs are unlikely to prevent additional Marathon-like scenarios. In this article, we describe in more detail the unique features of Emflaza compared with these other recent cases of drug price increases, determine the likelihood that similar situations will arise in the future, and explore legislative and administrative options to specifically prevent such behavior.

Orphans' perspectives on grief and loss in Botswana

This paper seeks to examine orphaned children's experiences on grief and loss in Botswana, and its impact on their well-being and make policy recommendations. A cross sectional design which utilized survey questionnaires was employed. Data were collected from 11 districts (3 urban and 8 rural) among orphan children aged 10-18 years. Chi-squared test was used to identify variables believed to be associated with loss and grief. Unadjusted (simple) and adjusted multiple logistic regression was used to investigate factors associated with loss. Of the 732 participants (53.1%) were females and mean age was 13.5 years (SD = 2.7); and 44.6% of these children had experienced death of a close family member in the past year which had been communicated. Children had access to education, lower primary (19.5%), upper primary (39.1%), junior secondary (32.5%), senior secondary school (6.6%), and (0.3%) in tertiary institutions. Most children (88.6%) had not experienced stigma and discrimination at school; 55.2% lived with grandparents, aunts (23.4%), siblings (11.8%), uncles (4.0%), other relatives (3.5%) and non-relatives (0.1%). Unadjusted logistic regression indicated that loss was significantly associated with having someone to talk to (OR = 0.72, 95% CI, 0.53-0.98, p = 0.03), change of residence (OR = 3.08, 95% CI, 1.94-4.90, p < 0.01), having siblings (OR = 2.06, 95% CI, 1.38-3.07, p < 0.01) and being from urban areas (OR = 0.56, 95% CI, 0.41-0.78, p < 0.01). In the adjusted model, loss was significantly associated with change of residence (OR = 2.72, 95% CI, 1.69-4.35, p < 0.01), having siblings (OR = 1.98, 95% CI, 1.30-3.01, p < 0.01) and being from urban areas (OR = 0.65, 95% CI, 0.46-0.93, p = 0.02). Age-specific interventions aimed at addressing the emotional, psychosocial and economic impacts of grief and loss are critical in preventing negative coping behaviors and improving the quality of life of orphans.

A qualitative analysis of parental loss and family separation among youth in post-conflict Liberia

Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war. In 2008, the population was approximately 3.5 million people, and there were an estimated 340,000 orphans. Nearly 6000 more children were orphaned by the Ebola epidemic from 2014-2015. The goal of this research was to explore the impact of parental loss, identify moderating factors, and consider interventions that could help vulnerable youth in post-conflict societies following the loss of a parent. Seventy-five young people (age 13-18 years) in Monrovia, the capital city of Liberia, were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. The loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. The timing of the loss, strength of connection with the deceased parent, and relationship with surviving parent or substitute caregiver were all relevant factors. Children separated from living parents were functioning better than those whose parents were deceased. The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. Children who did not experience stable early relationships suffered disconnection from their families and communities.

Impact of orphan status on HIV treatment outcomes and retention in care of children and adolescents in Asia

An analysis of the impact of orphanhood at antiretroviral therapy (ART) initiation on HIV outcomes in Asia included 4300 children; 51% were male. At ART initiation, 1805 (42%) were non-orphans (median age: 3 years), 1437 (33%) were single orphans (6 years) and 1058 (25%) were double orphans (7 years). Ten-year post-ART survival was 93.4-95.2% across orphan categories. Clinic transfers were higher among single and double orphans than non-orphans (41% vs 11%, P<0.001). On multivariate analysis, children ≥3 years at ART initiation (hazard ratio 1.58 vs <3 years, 95% confidence interval: 1.11-2.24) were more likely to be lost to follow-up. Although post-ART mortality and retention did not differ by orphan status, orphans were at greater risk of starting ART at older ages, and with more severe immunosuppression and poorer growth.

A price comparison of recently launched proprietary pharmaceuticals in the UK and the US

OBJECTIVE

To explore the relationship between prices charged by manufacturers of proprietary pharmaceuticals in the US and in the UK in recent years (2013-2016), expressed as a multiplier, and to detail to what extent this relationship differs for high-cost therapies used in smaller patient populations, as compared to lower-cost drugs.

METHODOLOGY

Therapies assessed by the Scottish Medicines Consortium (SMC) in the UK between 1 January 2013 and 1 June 2016 were identified; only in-patent therapies were included in the analysis (to avoid the impact of price erosion post patent expiry); results were grouped according to annual cost per patient (whether considered high-cost, i.e., >£2,500 per patient per year, or not) and the size of the UK target population [whether considered orphan (<32,000 patients per year), ultra-orphan (<1,000 patients per year), or not]. Publicly listed prices were obtained in the US and UK and were adjusted where necessary to estimate the prices charged by manufacturers in the respective countries. The difference in price (per unit of the same strength and formulation) was calculated as a multiplier between the US and UK prices for each of the therapies identified.

RESULTS

Based on the methodological approach described, 88 therapies were identified and included in the analysis. The multiplier between the US and UK prices was 3.64 for therapies with an estimated annual cost <£2,500; this was reduced to 1.90 for higher-cost therapies. A downward trend was also evident in the subgroup analysis of the higher-cost therapies; as the estimated target patient populations reduced from >32,000 down to <1,000, the US/UK price multipliers reduced from 2.13 for the former to 1.48 for the latter.

CONCLUSION

Although pharmaceutical prices have been found to be on average substantially higher in the US compared to the UK, our findings suggest that this price discrepancy is smaller for higher-cost therapies targeting small patient populations. Manufacturers of high-cost products should therefore factor this in when formulating pricing strategies because the potential for higher pricing in the US seems greater for primary care products targeting large patient populations.

Child prosociality within HIV-affected contexts: The impact of carer ill-health and orphan status

Considerable attention has been provided to the potential adverse outcomes for youth in the context of HIV and AIDS. Using data from a large community-based study on the psychosocial well-being of youth affected by HIV and AIDS, this paper advances a strength-based, resiliency perspective that is centred on the construct of prosociality. Data was derived from the Young Carers South Africa Project, where a cross-sectional household survey was conducted with 2,477 child-carer pairs in an HIV endemic community in the province of KwaZulu-Natal, South Africa. Analysis in this paper focuses on a subset of 2,136 child-carer pairs. Perceptions of child prosociality were assessed using the Prosocial Scale of the Strengths and Difficulties Questionnaire (SDQ). Both child and carer responses were obtained to provide insight into the functioning of carer-child dyads. Descriptive and inferential analysis was conducted to explore ratings of child prosociality across different relational contexts affected by HIV and involving care for orphaned youths. Dual-affected households, where carers are ill with opportunistic infections and youth are orphaned due to AIDS, yielded the highest discrepancies with carers reporting low child prosociality and children self-reporting high prosociality. Carer ill health appears to play a role in differentiating child prosociality across relational contexts involving non-orphaned youth. Further research is needed to explore child prosociality as a protective mechanism in high HIV-endemic communities.

QQS orphan gene regulates carbon and nitrogen partitioning across species via NF-YC interactions

The allocation of carbon and nitrogen resources to the synthesis of plant proteins, carbohydrates, and lipids is complex and under the control of many genes; much remains to be understood about this process. QQS (Qua-Quine Starch; At3g30720), an orphan gene unique to Arabidopsis thaliana, regulates metabolic processes affecting carbon and nitrogen partitioning among proteins and carbohydrates, modulating leaf and seed composition in Arabidopsis and soybean. Here the universality of QQS function in modulating carbon and nitrogen allocation is exemplified by a series of transgenic experiments. We show that ectopic expression of QQS increases soybean protein independent of the genetic background and original protein content of the cultivar. Furthermore, transgenic QQS expression increases the protein content of maize, a C4 species (a species that uses 4-carbon photosynthesis), and rice, a protein-poor agronomic crop, both highly divergent from Arabidopsis. We determine that QQS protein binds to the transcriptional regulator AtNF-YC4 (Arabidopsis nuclear factor Y, subunit C4). Overexpression of AtNF-YC4 in Arabidopsis mimics the QQS-overexpression phenotype, increasing protein and decreasing starch levels. NF-YC, a component of the NF-Y complex, is conserved across eukaryotes. The NF-YC4 homologs of soybean, rice, and maize also bind to QQS, which provides an explanation of how QQS can act in species where it does not occur endogenously. These findings are, to our knowledge, the first insight into the mechanism of action of QQS in modulating carbon and nitrogen allocation across species. They have major implications for the emergence and function of orphan genes, and identify a nontransgenic strategy for modulating protein levels in crop species, a trait of great agronomic significance.

Drug Discovery Opportunities at the Endothelin B Receptor-Related Orphan G Protein-Coupled Receptors, GPR37 and GPR37L1

Orphan G protein-coupled receptors (GPCRs) represent a largely untapped resource for the treatment of a variety of diseases, despite sophisticated advances in drug discovery. Two promising orphan GPCRs are the endothelin B receptor-like proteins, GPR37 [ET(B)R-LP, Pael-R] and GPR37L1 [ET(B)R-LP-2]. Originally identified through searches for homologs of endothelin and bombesin receptors, neither GPR37 nor GPR37L1 were found to bind endothelins or related peptides. Instead, GPR37 was proposed to be activated by head activator (HA) and both GPR37 and GPR37L1 have been linked to the neuropeptides prosaposin and prosaptide, although these pairings are yet to be universally acknowledged. Both orphan GPCRs are widely expressed in the brain, where GPR37 has received the most attention for its link to Parkinson’s disease and parkinsonism, while GPR37L1 deletion leads to precocious cerebellar development and hypertension. In this review, the existing pharmacology and physiology of GPR37 and GPR37L1 is discussed and the potential therapeutic benefits of targeting these receptors are explored.

Psychosocial support and parents' social life determine the self-esteem of orphan children

Parental death affects the life of children in many ways, one of which is self-esteem problems. Providing psychosocial support and equipping orphans play a vital role in their lifes. A cross-sectional study was conducted on 7-18-year-old orphans at 17 local districts of Gamo Gofa Zone, Southern Regional State of Ethiopia. From a total of 48,270 orphans in these areas, 4,368 were selected using stratified simple random sampling technique. Data were collected with a designed questionnaire based on the Rosenberg's rating scale to measure their self-esteem levels. Self-esteem with a score less than or equal to an average score was considered to be low self-esteem in the analysis. Binary logistic regression model was used to analyze the data using the SPSS software. The results of the study revealed that the probability of orphans suffering from low self-esteem was 0.59. Several risk factors were found to be significant at the level of 5%. Psychosocial support (good guidance, counseling and treatment, physical protection and amount of love shared, financial and material support, and fellowship with other children), parents living together before death, strong relationship between parents before death, high average monthly income, voluntary support, and consideration from the society are some of the factors that decrease the risk of being low in self-esteem. There are many orphans with low self-esteem in the study areas. The factors negatively affecting the self-esteem of orphans include the lack of psychosocial support, poor social life of parents, and death of parents due to AIDS. Society and parents should be aware of the consequences of these factors which can influence their children's future self-esteem.

Long Standing Eculizumab Treatment without Anticoagulant Therapy in High-Risk Thrombogenic Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is an ultra-orphan disease affecting all hematopoietic cell types. The abnormality of red blood cells in this disease predisposes to intravascular complement-mediated hemolysis. Eculizumab is an orphan drug used to treat this rare disease. Thrombosis is the key cause of death in PNH patients in about 40% to 67% of cases. We report the case of a woman presenting with PNH complicated with serious Budd-Chiari syndrome thrombosis and with a stent inserted in the portal vein. She refused to take any anticoagulant treatment since she commenced eculizumab 4 years before. No thrombotic events happened since that time. This case could add an extra benefit for eculizumab, which could be used as an anti-thromboembolic prophylactic agent in PNH, especially in patients with thrombocytopenia, where the use of anticoagulant agents is extremely hazardous. More randomized studies might establish the use of eculizumab without anticoagulants to avoid serious bleeding that could happen in thrombocytopenic PNH patients.

Remote homology and the functions of metagenomic dark matter

Predicted open reading frames (ORFs) that lack detectable homology to known proteins are termed ORFans. Despite their prevalence in metagenomes, the extent to which ORFans encode real proteins, the degree to which they can be annotated, and their functional contributions, remain unclear. To gain insights into these questions, we applied sensitive remote-homology detection methods to functionally analyze ORFans from soil, marine, and human gut metagenome collections. ORFans were identified, clustered into sequence families, and annotated through profile-profile comparison to proteins of known structure. We found that a considerable number of metagenomic ORFans (73,896 of 484,121, 15.3%) exhibit significant remote homology to structurally characterized proteins, providing a means for ORFan functional profiling. The extent of detected remote homology far exceeds that obtained for artificial protein families (1.4%). As expected for real genes, the predicted functions of ORFans are significantly similar to the functions of their gene neighbors (p < 0.001). Compared to the functional profiles predicted through standard homology searches, ORFans show biologically intriguing differences. Many ORFan-enriched functions are virus-related and tend to reflect biological processes associated with extreme sequence diversity. Each environment also possesses a large number of unique ORFan families and functions, including some known to play important community roles such as gut microbial polysaccharide digestion. Lastly, ORFans are a valuable resource for finding novel enzymes of interest, as we demonstrate through the identification of hundreds of novel ORFan metalloproteases that all possess a signature catalytic motif despite a general lack of similarity to known proteins. Our ORFan functional predictions are a valuable resource for discovering novel protein families and exploring the boundaries of protein sequence space. All remote homology predictions are available at http://doxey.uwaterloo.ca/ORFans.