Generic orphan drug substitution: a critical analysis of global practices and Saudi Arabia's perspective

In an era of cost pressure, substituting generic drugs represents one of the main cost-containment strategies of healthcare systems. Despite the obvious financial benefits, in a minority of cases, substitution may require caution or even be contraindicated. In most jurisdictions, to obtain approval, the bioequivalence of generic products with the brand-name equivalent needs to be shown via bioavailability studies in healthy subjects. Rare diseases, defined as medical conditions with a low prevalence, are a group of heterogenous diseases that are typically severe, disabling, progressive, degenerative, and life-threatening or chronically debilitating, and disproportionally affect the very young and elderly. Despite these unique features of rare diseases, generic bioequivalence studies are typically carried out with single doses and exclude children or the elderly. Furthermore, the excipients and manufacturing processes for generic/biosimilar products can differ from the brand products which may affect the shelf-life of the product, its appearance, smell, taste, bioavailability, safety and potency. This may result in approval of generics/biosimilars which are not bioequivalent/comparable in their target population or that meet bioequivalence but not therapeutic equivalence criteria. Another concern relates to the interchangeability of generics and biosimilars which cannot be guaranteed due to the phenomenon of biocreep. This review summarizes potential concerns with generic substitution of orphan drugs and discusses potentially problematic cases including narrow therapeutic index drugs or critical conditions where therapeutic failure could lead to serious complications or even death. Finally, we put forward the need for refining regulatory frameworks, with emphasis on Saudi Arabia, for generic substitution and recent efforts toward this direction.

Long-term outcomes after new onset seizure in children living with HIV: A cohort study

OBJECTIVE

To determine the long-term outcomes, including mortality and recurrent seizures, among children living with HIV (CLWH) who present with new onset seizure.

METHODS

Zambian CLWH and new onset seizure were enrolled prospectively to determine the risk of and risk factors for recurrent seizures. Demographic data, clinical profiles, index seizure etiology, and 30-day mortality outcomes were previously reported. After discharge, children were followed quarterly to identify recurrent seizures and death. Given the high risk of early death, risk factors for recurrent seizure were evaluated using a model that adjusted for mortality.

RESULTS

Among 73 children enrolled, 28 died (38%), 22 within 30-days of the index seizure. Median follow-up was 533 days (IQR 18-957) with 5% (4/73) lost to follow-up. Seizure recurrence was 19% among the entire cohort. Among children surviving at least 30-days after the index seizure, 27% had a recurrent seizure. Median time from index seizure to recurrent seizure was 161 days (IQR 86-269). Central nervous system opportunistic infection (CNS OI), as the cause for the index seizure was protective against recurrent seizures and higher functional status was a risk factor for seizure recurrence.

SIGNIFICANCE

Among CLWH presenting with new onset seizure, mortality risks remain elevated beyond the acute illness period. Recurrent seizures are common and are more likely in children with higher level of functioning even after adjusting for the outcome of death. Newer antiseizure medications appropriate for co-usage with antiretroviral therapies are needed for the care of these children. CNS OI may represent a potentially reversible provocation for the index seizure, while seizures in high functioning CLWH without a CNS OI may be the result of a prior brain injury or susceptibility to seizures unrelated to HIV and thus represent an ongoing predisposition to seizures.

PLAIN LANGUAGE SUMMARY

This study followed CLWH who experienced a new onset seizure to find out how many go on to have more seizures and identify any patient characteristics associated with having more seizures. The study found that mortality rates continue to be high beyond the acute clinical presentation with new onset seizure. Children with a CNS OI causing the new onset seizure had a lower risk of later seizures, possibly because the trigger for the seizure can be treated. In contrast, high functioning children without a CNS OI were at higher risk of future seizures.

Orphan peptide and G protein-coupled receptor signalling in alcohol use disorder

Neuropeptides and G protein-coupled receptors (GPCRs) have long been, and continue to be, one of the most popular target classes for drug discovery in CNS disorders, including alcohol use disorder (AUD). Yet, orphaned neuropeptide systems and receptors (oGPCR), which have no known cognate receptor or ligand, remain understudied in drug discovery and development. Orphan neuropeptides and oGPCRs are abundantly expressed within the brain and represent an unprecedented opportunity to address brain function and may hold potential as novel treatments for disease. Here, we describe the current literature regarding orphaned neuropeptides and oGPCRs implicated in AUD. Specifically, in this review, we focus on the orphaned neuropeptide cocaine- and amphetamine-regulated transcript (CART), and several oGPCRs that have been directly implicated in AUD (GPR6, GPR26, GPR88, GPR139, GPR158) and discuss their potential and pitfalls as novel treatments, and progress in identifying their cognate receptors or ligands.

Association between idiopathic hypersomnia and a genetic variant in the PER3 gene

We aim to identify genetic markers associated with idiopathic hypersomnia, a disabling orphan central nervous system disorder of hypersomnolence that is still poorly understood. In our study, DNA was extracted from 79 unrelated patients diagnosed with idiopathic hypersomnia with long sleep time at the National Reference Center for Narcolepsy-France according to very stringent diagnostic criteria. Whole exome sequencing on the first 30 patients with idiopathic hypersomnia (25 females and 5 males) allowed the single nucleotide variants to be compared with a control population of 574 healthy subjects from the French Exome project database. We focused on the identification of genetic variants among 182 genes related to the regulation of sleep and circadian rhythm. Candidate variants obtained by exome sequencing analysis were then validated in a second sample of 49 patients with idiopathic hypersomnia (37 females and 12 males). Our study characterised seven variants from six genes significantly associated with idiopathic hypersomnia compared with controls. A targeted sequencing analysis of these seven variants on 49 other patients with idiopathic hypersomnia confirmed the relative over-representation of the A➔C variant of rs2859390, located in a potential splicing-site of PER3 gene. Our findings support a genetic predisposition and identify pathways involved in the pathogeny of idiopathic hypersomnia. A variant of the PER3 gene may predispose to idiopathic hypersomnia with long sleep time.

Providing Adaptation Solutions to the Problems Faced by Adoptive Families

BACKGROUND

Adoption is frequently viewed as a way to complete the family because of the infertility that some families experience and the desire for kids and teenagers, especially orphans, to have a loving family.

AIMS

This work intends to identify and propose adaptation solutions to address the psychological problems faced by adoptive families. By doing so, it is hoped that the mental health and overall well-being of individuals and society as a whole will be enhanced.

MATERIALS AND METHODS

In the first stage of this study, the grounded theory approach based on Strauss and Corbin's methodology was used to interview representatives of adoptive families in Iran in 2022 and identify the problems they experience. In the second stage, the same approach and methodology were used to interview representatives of experts. In the second stage, the results of the first stage were presented to a sample of purposefully selected experts, who subsequently proposed solutions for the families to adapt to their problems. Data analysis was conducted using MAXQDA 2020 software (VERBI Software, Berlin, Germany). Ethical requirements were followed at every stage of the study.

RESULTS

Four problem categories were identified in the first step of the study: legal-psychological problems, problems related to the growth of the child in an environment of social harm, attitude and worldview, and the resilience of the adoptive couple. In the second step of the study, four groups of solutions for psychological adjustment were extracted: explaining the issue of what, how, and why of adoption (correct identification of the problems faced by adoptive families, clarification of concepts and demystification, the need for research to address other gaps in the knowledge infrastructure, and the importance of critical thinking education), operational solutions (supervising the adoption database to become more efficient, unitization of adoption national institutes in each province, selection of officials based on both factors of professional and complete mental health, alignment of the provisions and other related legal matters between the involved institutions, and utilization of media influence are recommended, interactional solutions for family resilience (cognitive-therapeutic interactions for mental health based on flexibility, raising the family's social capacity through active counseling, improving problem-solving skills, fostering family self-efficacy, creating purposefulness, and appropriate beliefs to predict a bright future), attitude-changing solutions (redefining social norms and facilitating the adoption of desired attitudes by employing social psychology principles, exploiting the power of media and influential figures, employing techniques derived from the psychology of learning, establishing conducive conditions within the framework of individuals' cognitive dissonance to modify their attitudes, and employing persuasion strategies).

CONCLUSION

Legislators and law enforcers, adoptive families, psychologists and consultants working in this field, and physicians specializing in infertility treatment can benefit from the findings of this study.

Children orphaned from COVID-19 in Thailand: maximize use of civil registration database for policies

Orphans, especially those who experience maternal loss at a young age, face significant long-term negative impacts on their lives and psychological well-being, extending beyond the age of 18. As of July 2023, the global death toll of COVID-19 has reached 6.9 million, leaving behind an unknown number of orphans who require immediate attention and support from policymakers. In Thailand, from April 2020 to July 2022, the total number of COVID-19-related deaths reached 42,194, resulting in 4,139 parental orphans. Among them, 452 (10.9%) were children under the age of five, who are particularly vulnerable and necessitate special policy attention and ongoing support. While the provision of 12 years of free education for all and Universal Health Coverage helps alleviate the education and health expenses borne by households supporting these orphans, the monthly government support of 2,000 Baht until the age of 18 is insufficient to cover their living costs and other education-related expenditures. We advocate for adequate financial and social support for COVID-19 orphans, emphasizing the importance of placing them with relatives rather than institutional homes. In the context of post-pandemic recovery, this perspective calls upon governments and global communities to estimate the number of orphans and implement policies to safeguard and support them in the aftermath of COVID-19.

Characterisation of Type II DNA Methyltransferases of Metamycoplasma hominis

Bacterial virulence, persistence and defence are affected by epigenetic modifications, including DNA methylation. Solitary DNA methyltransferases modulate a variety of cellular processes and influence bacterial virulence; as part of a restriction-modification (RM) system, they act as a primitive immune system in methylating the own DNA, while unmethylated foreign DNA is restricted. We identified a large family of type II DNA methyltransferases in Metamycoplasma hominis, comprising six solitary methyltransferases and four RM systems. Motif-specific 5mC and 6mA methylations were identified with a tailored Tombo analysis on Nanopore reads. Selected motifs with methylation scores >0.5 fit with the gene presence of DAM1 and DAM2, DCM2, DCM3, and DCM6, but not for DCM1, whose activity was strain-dependent. The activity of DCM1 for C^mCWGG and of both DAM1 and DAM2 for G^mATC was proven in methylation-sensitive restriction and finally for recombinant rDCM1 and rDAM2 against a dam-, dcm-negative background. A hitherto unknown dcm8/dam3 gene fusion containing a (TA) repeat region of varying length was characterized within a single strain, suggesting the expression of DCM8/DAM3 phase variants. The combination of genetic, bioinformatics, and enzymatic approaches enabled the detection of a huge family of type II DNA MTases in M. hominis, whose involvement in virulence and defence can now be characterized in future work.

Growth Anthropometrics as a Metric of Malnutrition Disparities Among Young Children Affected by HIV who are Orphaned Maternally, Paternally, or Totally in Western Kenya: A Retrospective Chart Review

This retrospective study investigated growth outcomes of Kenyan children born to women living with HIV, comparing children who were orphaned maternally, paternally, and totally (both parents deceased) to those who were non-orphaned. We reviewed HIV clinic visits performed in Kenya from January 2011 to August 2016 in children 0 to 4 years of age. Malnutrition was assessed using stunting, underweight status, and wasting (z-scores of ≤-2). Descriptive statistics, Chi-square, t-tests, multivariable logistic regression, and ANCOVA models were performed. Of 15 027 total children in the study population, 3.5% (n = 520) were orphaned maternally, 8.1% (n = 1222) were orphaned paternally, and 2.2% (n = 336) were orphaned totally. Children who were orphans had higher rates of malnutrition compared to non-orphans (P < .001). Children who were orphaned maternally and totally had lower anthropometric mean scores, presented to clinic later, and were more likely to be living with HIV. Children who are orphaned maternally or totally should be targeted in interventional strategies.

Development and Implementation of a Nutritional Education Program Aimed at Improving the Integration Process of Young Orphan Refugees Newly Arrived in Portugal

(1) Background: Refugees are a population group at imminent risk of death, being forced to migrate to countries with different cultures. Many of the refugees are at great risk of malnutrition, especially adolescent orphans. The aim of the study was to establish a nutritional and food education program to improve the integration process of young orphan refugees newly arrived in Portugal. (2) Methods: A nutrition and food education program with nine sessions of food and nutrition education over 12 weeks was carried out by a nutritionist from March to June 2016, in 15 young residents of the Reception Center for Refugee Children. The program included the application of a nutritional knowledge questionnaire, an anthropometric assessment, and the collection of data on food habits and lifestyle. The evaluation of the program was carried out by comparing the initial and final scores of the nutritional knowledge questionnaire. (3) Results: There was an improvement in nutritional knowledge among the adolescents, and a direct relationship between attendance at the sessions and improvement of this knowledge was found. Non-significant changes were observed in some anthropometric measurements between the beginning and the ending of the program. (4) Conclusions: This food education program contributed to a better understanding by young orphan refugees newly arrived in Portugal of the foods available in Portugal and of the Portuguese gastronomy.

Orphaning stunts growth in wild African elephants

Orphans of several species suffer social and physiological consequences such as receiving more aggression from conspecifics and lower survival. One physiological consequence of orphaning, stunted growth, has been identified in both humans and chimpanzees, but has not been assessed in a non-primate species. Here, we tested whether wild African elephant orphans show evidence of stunted growth. We measured individually known female elephants in the Samburu and Buffalo Springs National Reserves of Kenya, with a rangefinder capable of calculating height, to estimate a von Bertalanffy growth curve for female elephants of the study population. We then compared measurements of known orphans and non-orphans of various ages, using a Bayesian analysis to assess variation around the derived growth curve. We found that orphans are shorter for their age than non-orphans. However, results suggest orphans may partially compensate for stunting through later growth, as orphans who had spent a longer time without their mother had heights more similar to non-orphans. More age mates in an individual's family were associated with taller height, suggesting social support from peers may contribute to increased growth. Conversely, more adult females in an individual's family were associated with shorter height, suggesting within-group competition for resources with older individuals may reduce juvenile growth. Finally, we found a counterintuitive result that less rainfall in the first 6 years of life was correlated with taller height, potentially reflecting the unavoidable bias of measuring individuals who were fit enough to survive conditions of low rainfall as young calves. Reduced growth of individuals has been shown to reduce survival and reproduction in other species. As such, stunting in wildlife orphans may negatively affect fitness and represents an indirect effect of ivory poaching on African elephants.

Polarized adult fertility patterns following early parental death

Death of a parent during childhood has become rare in developed countries but remains an important life course event that may have consequences for family formation. This paper describes the link between parental death before age 18 and fertility outcomes in adulthood. Using the large national 2011 French Family Survey (INSEE-INED), we focus on the 1946-66 birth cohorts, for whom we observe entire fertility histories. The sample includes 11,854 respondents who have lost at least one parent before age 18. We find a strong polarization of fertility behaviours among orphaned males, more pronounced for those coming from a disadvantaged background. More often childless, particularly when parental death occurred in adolescence, some seem to retreat from parenthood. But orphaned men and women who do become parents seem to embrace family life, by beginning childbearing earlier and having more children, especially when the deceased parent is of the same sex.

Orphan GPR146: an alternative therapeutic pathway to achieve cholesterol homeostasis?

Atherosclerosis predisposes to myriad cardiovascular complications, including myocardial infarction and stroke. Statins have revolutionised cholesterol management but they do not work for all patients, particularly those with familial hypercholesterolaemia (FH). Genome-wide association studies have linked SNPs at orphan G protein-coupled receptor 146 (GPR146) to human atherosclerosis but how GPR146 influences serum cholesterol homeostasis was only recently described. Gpr146 deletion in mice reduces serum cholesterol and atherosclerotic plaque burden, confirming GPR146 as a potential therapeutic target for managing circulating cholesterol. Critically, this effect was independent of the low-density lipoprotein receptor. While still an orphan, the activation of GPR146 by serum suggests identification of its endogenous ligand is tantalisingly close. Herein, we discuss the evidence for GPR146 inhibition as a treatment for atherosclerosis.

Violence Exposure, Self-Reported Mental Health Concerns and Use of Alcohol and Drugs for Coping among Youth in the Slums of Kampala, Uganda

This study aimed to a) compute the prevalence of violence exposure types, polyvictimization, and self-reported depression, anxiety, and using substances to cope among youth ages 12 to 18 years living on the streets or in the slums of Kampala, Uganda, (b) examine the independent associations among orphan status, violence exposure types, and self-reported mental health concerns, and c) explore the association between polyvictimization and mental health concerns. Data are from a 2014 cross-sectional survey of service-seeking youth ages 12 to 18 years (N = 1134) in Kampala, Uganda. Violence exposure types explored in this study were: witnessing family physical violence, direct physical abuse by a parent, any rape history, and physical dating violence. We used descriptive statistics and multivariable logistic regression to test study objectives. Over half of the sample (60.5%) reported experiencing at least one type of violence exposure; many youth endorsed self-reported depression (57.8%), anxiety (76.8%), and substance use to cope (37.0%). Exposure to violence was associated with higher odds for self-reported depression, anxiety, and using substances to cope. These findings underscore the urgent need to implement evidence-based interventions among this young, underserved population and their families to prevent violence, improve mental health outcomes, and promote resilience.

Orphan receptors in prostate cancer

BACKGROUND

The identification of new cellular receptors has been increasing rapidly. A receptor is called "orphan" if an endogenous ligand has not been identified yet.

METHODS

Here we review receptors that contribute to prostate cancer and are considered orphan or partially orphan. This means that the full spectrum of their endogenous ligands remains unknown.

RESULTS

The orphan receptors are divided into two major families. The first group includes G protein-coupled receptors. Most are orphan olfactory receptors. OR51E1 inhibits cell proliferation and induces senescence in prostate cancer. OR51E2 inhibits prostate cancer growth, but promotes invasiveness and metastasis. GPR158, GPR110, and GPCR-X play significant roles in prostate cancer development and progression. However, GPR160 induces cell cycle arrest and apoptosis. The other major subset of orphan receptors are nuclear receptors. Receptor-related orphan receptor α (RORα) inhibits tumor growth, but RORγ stimulates androgen receptor signaling. PXR contributes to metabolic deactivation of androgens and inhibits cell proliferation. TLX has protumorigenic effects in prostate cancer, while its knockdown triggers cellular senescence and growth arrest. Estrogen-related receptor ERRγ can inhibit tumor growth but ERRα is protumorigenic. Dax1 and short heterodimeric partner are also inhibitory in prostate cancer.

CONCLUSION

There is a "zoo" of relatively underappreciated orphan receptors that play key roles in prostate cancer.

Orphans in post-conflict Liberia: Seeking care in fractured communities

Orphans in post-conflict settings have unique needs that have not been well-characterized. In post-conflict Liberia, maternal orphans are more likely to be without care than paternal orphans. This study examined the experiences of maternal orphans in Liberia, as they attempted to care for themselves and seek care from others, and the barriers they faced. In-depth interviews were conducted with 75 post-conflict Liberian orphans. We performed a secondary narrative analysis of interview transcripts from all maternal or double orphans (n = 17). We identified similar elements across narratives: traumatic loss, disconnection from family and community, and the desire for a savior. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing. Sex also played a role in the provision of caregiving; substitute care was provided by women. Findings highlighted the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions are needed to improve access to mental health care, sober communities, housing, and education support. The need to integrate these services into indigenous institutions and address barriers related to stigma is explored.

Spoligotyping of Clinical Isolates of Mycobacterium tuberculosis Complex Species in the Oromia Region of Ethiopia

Background

Tuberculosis (TB) is a leading cause of morbidity and mortality in Ethiopia. Investigation of the Mycobacterium tuberculosis complex (MTBC) species circulating in the Ethiopian population would contribute to the efforts made to control TB in the country. Therefore, this study was conducted to investigate the MTBC species and spoligo patterns in the Oromia region (central) of Ethiopia.

Methods

A cross-sectional study design was used to recruit 450 smear positive pulmonary TB (PTB) cases from the Oromia region between September 2017 and August 2018. Mycobacteria were isolated from sputum samples on the Lowenstein Jensen (LJ) medium. Molecular identification of the isolates was performed by spoligotyping. The results of spoligotyping were transferred into a query box in the SITVIT2 database and Run TB-Lineage in the TB Insight website for the identification of spoligo international type (SIT) number and linages of the isolates, respectively. Statistical Product and Service Solutions (SPSS) 20 was applied for statistical analysis.

Results

Three hundred and fifteen isolates were grouped under 181 different spoligotype patterns. The most dominantly isolated spoligotype pattern was SIT149 and it consisted of 23 isolates. The majority of the isolates were grouped under Euro-American (EA), East-African-Indian (EAI), and Indo-Oceanic (IO) lineages. These lineages consisted of 79.4, 9.8, and 9.8% of the isolates, respectively. One hundred and sixty-five of the isolates were classified under 31 clustered spoligotypes whereas the remaining 150 were singleton types. Furthermore, 91.1% of the total isolates were classified as orphan types. Clustering of spoligotypes was associated (p < 0.001) with EAI lineage.

Conclusion

SIT149 and EA lineage were predominantly isolated from the Oromia region substantiating the findings of the similar studies conducted in other regions of Ethiopia. The observation of significant number of singleton and orphan spoligotypes warrants for additional genetic typing of the isolates using method(s) with a better discriminatory power than spoligotyping.

oryzae in Rice

All genomes carry lineage-specific orphan genes lacking homology in their closely related species. Identification and functional study of the orphan genes is fundamentally important for understanding lineage-specific adaptations including acquirement of resistance to pathogens. However, most orphan genes are of unknown function due to the difficulties in studying them using helpful comparative genomics. Here, we present a defense-related Oryza-specific orphan gene, Xio1, specifically induced by the bacterial pathogen Xanthomonas oryzae pv. oryzae (Xoo) in an immune receptor XA21-dependent manner. Salicylic acid (SA) and ethephon (ET) also induced its expression, but methyl jasmonic acid (MeJA) reduced its basal expression. C-terminal green fluorescent protein (GFP) tagged Xio1 (Xio1-GFP) was visualized in the nucleus and the cytosol after polyethylene glycol (PEG)-mediated transformation in rice protoplasts and Agrobacterium-mediated infiltration in tobacco leaves. Transgenic rice plants overexpressing Xio1-GFP showed significantly enhanced resistance to Xoo with reduced lesion lengths and bacterial growth, in company with constitutive expression of defense-related genes. However, all of the transgenic plants displayed severe growth retardation and premature death. Reactive oxygen species (ROS) was significantly produced in rice protoplasts constitutively expressing Xio1-GFP. Overexpression of Xio1-GFP in non-Oryza plant species, Arabidopsis thaliana, failed to induce growth retardation and enhanced resistance to Pseudomonas syringae pv. tomato (Pst) DC3000. Our results suggest that the defense-related orphan gene Xio1 plays an important role in distinctive mechanisms evolved within the Oryza and provides a new source of Oryza-specific genes for crop-breeding programs.

Feline neonatology: From birth to commencement of weaning - what to know for successful management

PRACTICAL RELEVANCE

Despite considerable interest in the field of companion animal reproduction, feline neonatology remains largely unstudied. This contrasts with the need for a more professional veterinary approach to newborn kittens and feline husbandry, across the pet, breeding cattery and rescue shelter settings, to reduce kitten mortality.

GLOBAL IMPORTANCE

Feline neonatology has relevance for veterinarians around the world as cats are continuing to become established as popular companion animals.

CLINICAL CHALLENGES

Perinatal mortality in cats is remarkably high. Therefore, adequate neonatal evaluation and assistance at birth, careful monitoring of kittens in the vulnerable period until weaning begins, assessment of maternal factors and well-informed management of orphans are crucial in helping to reduce kitten losses.

AIM

This review aims to deepen the basic knowledge of the veterinary clinical team regarding the characteristics of feline newborns under normal conditions at birth through to the commencement of weaning. Much of the information is also relevant to breeders and rescue/shelter caregivers.

EVIDENCE BASE

In compiling the present review, the authors have drawn on specific feline research data, where available, complemented by data extrapolated from scientific publications on newborn dogs, and also their own and their colleagues' professional clinical experience.

Poaching of African elephants indirectly decreases population growth through lowered orphan survival

Prolonged maternal care is vital to the well-being of many long-lived mammals.¹ The premature loss of maternal care, i.e., orphaning, can reduce offspring survival even after weaning is complete.^2-5 However, ecologists have not explicitly assessed how orphaning impacts population growth. We examined the impact of orphaning on population growth in a free-ranging African elephant population, using 19 years of individual-based demographic monitoring data. We compared orphan and nonorphan survival, performed a sensitivity analysis to understand how population growth responds to the probability of being orphaned and orphan survival, and investigated how sensitivity to these orphan parameters changed with level of poaching. Orphans were found to have lower survival compared to nonorphaned age mates, and population growth rate was negatively correlated with orphaning probability and positively correlated with orphan survival. This demonstrates that, in addition to its direct effects, adult elephant death indirectly decreases population growth through orphaning. Population growth rate's sensitivity to orphan survival increased for the analysis parameterized using only data from years of more poaching, indicating orphan survival is more important for population growth as orphaning increases. We conclude that orphaning substantively decreases population growth for elephants and should not be overlooked when quantifying the impacts of poaching. Moreover, we conclude that population models characterizing systems with extensive parental care benefit from explicitly incorporating orphan stages and encourage research into quantifying effects of orphaning in other social mammals of conservation concern.

Early maternal loss leads to short- but not long-term effects on diurnal cortisol slopes in wild chimpanzees

The biological embedding model (BEM) suggests that fitness costs of maternal loss arise when early-life experience embeds long-term alterations to hypothalamic-pituitary-adrenal (HPA) axis activity. Alternatively, the adaptive calibration model (ACM) regards physiological changes during ontogeny as short-term adaptations. Both models have been tested in humans but rarely in wild, long-lived animals. We assessed whether, as in humans, maternal loss had short- and long-term impacts on orphan wild chimpanzee urinary cortisol levels and diurnal urinary cortisol slopes, both indicative of HPA axis functioning. Immature chimpanzees recently orphaned and/or orphaned early in life had diurnal cortisol slopes reflecting heightened activation of the HPA axis. However, these effects appeared short-term, with no consistent differences between orphan and non-orphan cortisol profiles in mature males, suggesting stronger support for the ACM than the BEM in wild chimpanzees. Compensatory mechanisms, such as adoption, may buffer against certain physiological effects of maternal loss in this species.

GPR182 is an endothelium-specific atypical chemokine receptor that maintains hematopoietic stem cell homeostasis

G protein–coupled receptors (GPCRs) are important regulators of cellular and biological functions and are primary targets of therapeutic drugs. About 100 mammalian GPCRs are still considered orphan receptors because they lack a known endogenous ligand. We report the deorphanization of GPR182, which is expressed in endothelial cells of the microvasculature. We show that GPR182 is an atypical chemokine receptor, which binds CXCL10, 12, and 13. However, binding does not induce downstream signaling. Consistent with a scavenging function of GPR182, mice lacking GPR182 have increased plasma levels of chemokines. In line with the crucial role of CXCL12 in hematopoietic stem cell homeostasis, we found that loss of GPR182 results in increased egress of hematopoietic stem cells from the bone marrow.

G protein–coupled receptor 182 (GPR182) has been shown to be expressed in endothelial cells; however, its ligand and physiological role has remained elusive. We found GPR182 to be expressed in microvascular and lymphatic endothelial cells of most organs and to bind with nanomolar affinity the chemokines CXCL10, CXCL12, and CXCL13. In contrast to conventional chemokine receptors, binding of chemokines to GPR182 did not induce typical downstream signaling processes, including G_q- and G_i-mediated signaling or β-arrestin recruitment. GPR182 showed relatively high constitutive activity in regard to β-arrestin recruitment and rapidly internalized in a ligand-independent manner. In constitutive GPR182-deficient mice, as well as after induced endothelium-specific loss of GPR182, we found significant increases in the plasma levels of CXCL10, CXCL12, and CXCL13. Global and induced endothelium-specific GPR182-deficient mice showed a significant decrease in hematopoietic stem cells in the bone marrow as well as increased colony-forming units of hematopoietic progenitors in the blood and the spleen. Our data show that GPR182 is a new atypical chemokine receptor for CXCL10, CXCL12, and CXCL13, which is involved in the regulation of hematopoietic stem cell homeostasis.

Undernutrition among Institutionalized School-age Orphans in Harari Regional State, Eastern Ethiopia: A Cross-sectional Study

Background:

Although orphans are at increased risk of undernutrition, studies assessing prevalence of undernutrition are limited to orphans residing with their relatives or on street. This study was conducted to assess magnitude of undernutrition and its associated factors among institutionalized school-age orphans in Harari Regional State, eastern Ethiopia.

Methods:

An institution based cross-sectional study was conducted among all school-age (6-12 years) orphans living in all orphan centers in Harari Regional State, eastern Ethiopia. Data were collected by using a structured pretested questionnaire supplemented with anthropometric measurements. Data were entered using EpiData 3.1 and analyzed using SPSS 22. Logistic regression models were fitted to identify factors associated with undernutrition. Statistical significance was declared at P-value <.05.

Results:

A total of 265 orphans residing in all orphan centers in the region were included. The prevalence of stunting, wasting, and underweight were 15.8% (95% CI: 11.9, 20.7), 10.9% (95% CI: 7.7, 15.3), and 8.7% (95% CI: 4.3, 10.5), respectively. Staying in orphan center for 6 to 10 years (AOR = 6.2; 95% CI: 2.6, 15.10), having recent illness (AOR = 3.9; 95% CI: 1.4, 10.4), and being aged 10 to 12 years (AOR = 11.2; 95% CI: 3.5, 35.4) were significantly associated with stunting whereas having recent illness (AOR = 4.3; 95% CI: 1.4, 7.3) and being aged 6 to 7 years (AOR: 10.4; 95% CI: 3.2, 33.6) were significantly associated with wasting. Underweight was more likely (AOR: 8.9; 95% CI: 2.7, 29.5) among children with recent illness.

Conclusions:

Almost 1 in 6, 1 in 9, and 1 in 11 institutionalized school-age orphans in Harari Regional State were stunted, wasted, and underweight respectively. Younger children and those with recent illness were more likely to be undernourished. Underlying reasons for undernutrition among orphans being cared in orphan centers should be further explored.

Social groups buffer maternal loss in mountain gorillas

Mothers are crucial for mammals’ survival before nutritional independence, but many social mammals reside with their mothers long after. In these species the social adversity caused by maternal loss later in life can dramatically reduce fitness. However, in some human populations these negative consequences can be overcome by care from other group members. We investigated the consequences of maternal loss in mountain gorillas and found no discernible fitness costs to maternal loss through survival, age at first birth, or survival of first offspring through infancy. Social network analysis revealed that relationships with other group members, particularly dominant males and those close in age, strengthened following maternal loss. In contrast to most social mammals, where maternal loss causes considerable social adversity, in mountain gorillas, as in certain human populations, this may be buffered by relationships within cohesive social groups, breaking the link between maternal loss, increased social adversity, and decreased fitness.

Most mammals depend entirely upon their mothers when they are born. In these species, losing a mother at a young age has dramatic consequences for survival. In cases where orphaned individuals do reach adulthood, they often suffer negative effects, like reduced reproductive success or lower social status. But this is not the case for humans. If a child loses their mother, relatives, friends and the wider community can take over. This does not tend to happen in nature. Even our closest relatives, chimpanzees, are much less likely to survive if their mothers die before they reach adolescence.

Although orphan survival is not the norm for mammals, humans may not be entirely unique. Mountain gorillas also live in stable family groups, usually with a dominant male and one or more females who care for their offspring for between 8 and 15 years. It is possible that gorillas may also be able to provide community support to orphans, which could buffer the costs of losing a mother, just as it does in humans.

To answer this question, Morrison et al. examined 53 years of data collected by the Dian Fossey Gorilla Fund to assess the effects of maternal loss in mountain gorillas. The analysis examined survival, reproduction and changes in social relationships. This revealed that, like humans, young gorillas that lose their mothers are not at a greater risk of dying. There is also no clear long-term effect on their ability to reproduce. In fact, gorillas who lost their mothers ended up with stronger social relationships, especially with the dominant male of the group and young gorillas around the same age. It seems that gorilla social groups, like human families, provide support to young group members that lose their mothers.

These findings suggest that the human ability to care for others in times of need may not be unique. It is possible that the tendency to care for orphaned young has its origins in our evolutionary past. Understanding this in more depth could provide clues into the social mechanisms that help to overcome early life adversity, and have a positive impact on future health and survival.

Meeting the orphan: early relational trauma, synchronicity and the psychoid

In this paper I attempt to show how deep engagement, which is gradually developed within the relational container, can facilitate access to the psychoid dimension of the unconscious characterized by a quality of interconnectedness. The resulting synchronistic experiences can support and strengthen this container as well as having profound re-connecting impact on the people involved. With this in mind, I suggest that openness to this dimension can be very important in working with the issues of loss, abandonment, aloneness and mistrust in human connections - the symbolic domain of the orphan. Although none of the patients I describe in this paper were actual orphans, symbolically the orphan theme featured significantly in their processes, in that early relational trauma left them feeling profoundly alone and unable to trust human contact. For this reason, the most important yet difficult challenge of the work was to help them restore their sense of connectedness to themselves and to others. I consider the role of attunement and reverie as the basis for facilitating this openness and propose that such openness can be seen as a feature of the analytic attitude in its own right and that it constitutes a unique contribution of the Jungian approach to working with early trauma.

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.

Census of solo LuxR genes in prokaryotic genomes

luxR genes encode transcriptional regulators that control acyl homoserine lactone-based quorum sensing (AHL QS) in Gram negative bacteria. On the bacterial chromosome, luxR genes are usually found next or near to a luxI gene encoding the AHL signal synthase. Recently, a number of luxR genes were described that have no luxI genes in their vicinity on the chromosome. These so-called solo luxR genes may either respond to internal AHL signals produced by a non-adjacent luxI in the chromosome, or can respond to exogenous signals. Here we present a survey of solo luxR genes found in complete and draft bacterial genomes in the NCBI databases using HMMs. We found that 2698 of the 3550 luxR genes found are solos, which is an unexpectedly high number even if some of the hits may be false positives. We also found that solo LuxR sequences form distinct clusters that are different from the clusters of LuxR sequences that are part of the known luxR-luxI topological arrangements. We also found a number of cases that we termed twin luxR topologies, in which two adjacent luxR genes were in tandem or divergent orientation. Many of the luxR solo clusters were devoid of the sequence motifs characteristic of AHL binding LuxR proteins so there is room to speculate that the solos may be involved in sensing hitherto unknown signals. It was noted that only some of the LuxR clades are rich in conserved cysteine residues. Molecular modeling suggests that some of the cysteines may be involved in disulfide formation, which makes us speculate that some LuxR proteins, including some of the solos may be involved in redox regulation.