From adaptive licensing to adaptive pathways: delivering a flexible life-span approach to bring new drugs to patients.

The concept of adaptive licensing (AL) has met with considerable interest. Yet some remain skeptical about its feasibility. Others argue that the focus and name of AL should be broadened. Against this background of ongoing debate, we examine the environmental changes that will likely make adaptive pathways the preferred approach in the future. The key drivers include: growing patient demand for timely access to promising therapies, emerging science leading to fragmentation of treatment populations, rising payer influence on product accessibility, and pressure on pharma/investors to ensure sustainability of drug development. We also discuss a number of environmental changes that will enable an adaptive paradigm. A life-span approach to bringing innovation to patients is expected to help address the perceived access vs. evidence trade-off, help de-risk drug development, and lead to better outcomes for patients.

EUROPLAN: a project to support the development of national plans on rare diseases in Europe.

BACKGROUND/AIMS: National Plans for Rare Diseases (RDs) are the common denominator of current public health policy concerns on RDs across the EU. With the aim of a better distribution of the available resources, they conjugate the European objective that aims at ensuring that patients with RDs have access to high-quality care - including diagnostics, treatment and rehabilitation - with the national priorities of selecting specific measures for adoption and implementation. METHODS: The European Project for Rare Diseases National Plans Development (EUROPLAN, www.europlanproject.eu) is cofunded by the EU Commission (DG-SANCO) and is coordinated by the Italian National Center for Rare Diseases of the Istituto Superiore di Sanità (ISS). The EUROPLAN goal is to promote the implementation of National Plans or Strategies to tackle RDs and share relevant experiences within countries, linking national efforts, through a common strategy at a European level. In order to fulfill these objectives, EUROPLAN involved health authorities, clinicians, scientists, the European Organisation for Rare Diseases (EURORDIS), and many other patient groups as associated and collaborating partners from several European countries. RESULTS: The project was launched in 2008 and foresaw 2 implementation phases: phase 1 (2008-2011) to build the consensus definition of operational tools (recommendations and indicators), and the ongoing phase 2 (2012-2015), mainly aimed at capacity building with the proactive involvement of multilevel stakeholders. EUROPLAN is facilitating and accelerating the implementation of National Plans in almost all EU and several non-EU Countries. CONCLUSIONS: EUROPLAN is a European and an international process more than a project, and it could be defined as a 'litmus test' demonstrating how the collaboration between institutions and patients' associations can accelerate the process of awareness and development of policies and actions.

Involvement of patient organisations in research and development of orphan drugs for rare diseases in europe.

Patients' representatives have an increasingly present voice in all aspects of drug development from fundamental research through regulatory processes to health technology assessment. Although major advances have been made in raising awareness and increasing funding for rare diseases, important challenges remain in terms of best use of resources, coordinating efforts and improving policy. This article describes actions taken by rare disease patients' organisations as well as initiatives at the national and European levels to promote research into rare diseases. A survey conducted by EURORDIS (European Organisation for Rare Diseases) on the support (financial and non-financial) provided by patients' organisations in rare disease research is described as well as the involvement of patients' representatives in regulatory processes for medicinal products at the European Medicines Agency. The importance of including patients' groups in fundamental and clinical research as equal partners has become a fact that clearly contributes to the success of an application and the research conducted.

Ivermectin is an effective treatment for bovine cutaneous papillomatosis.

This study aimed to evaluate the effectiveness of ivermectin on the treatment of bovine cutaneous papillomatosis. Twenty-four Holstein calves between 9 and 17 months of age with cutaneous papillomatosis were placed into three groups with six in group I, and nine in groups II and III. Group I served as a control group and received no treatment. Ivermectin at a dose of 0.2mg/kg was administered subcutaneously as a single dose to the animals in Group II and twice with 15 days intervals to animals in Group III. The first ivermectin application was considered as the 0th day Animals were monitored at 15 days intervals up to 3 months. No remission was observed in the control group (Group I). In Group II eight out of nine animals (88.8%) and in Group III seven out of nine animals (77.7%) showed complete recovery within 3 month observation period. It was concluded that ivermectin, as either single or double dose applications, is effective as a treatment for cutaneous papillomatosis.

Evaluation of some coagulation parameters in hepatic coccidiosis experimentally induced with Eimeria stiedai in rabbits.

The objective of this study was to evaluate some coagulation parameters in hepatic coccidiosis experimentally induced with Eimeria stiedai in rabbits. Fourteen healthy New Zealand rabbits were equally divided into two groups. One group received no treatment, the other group was orally inoculated with 40 000 sporulated oocysts of E. stiedai in a 1 ml inoculum using a catheter. At day 24 after inoculation, blood samples were collected into sodium citrate-containing tubes to evaluate some coagulation parameters. Although statistically not significant, infected rabbits had prolonged prothrombin time and activated partial thromboplastin time compared with rabbits in the control group. A significant reduction (P < 0.05) was observed in the level of fibrinogen of infected rabbits compared with that of the controls. A slight decrease in thrombocyte counts of infected rabbits was not statistically significant.

Experimental Aspergillus fumigatus infection in quails and results of treatment with itraconazole.

This study was performed to investigate (i). the clinical, histopathological and biochemical changes in quails (Coturnix coturnix japonica) with experimentally induced aspergillosis; and (ii). the efficiency of itraconazole treatment on these infected birds. A total of 18021-day-old male quails was randomly divided into three groups (control, infected untreated and infected treated), each containing 60. The experimental infection was set by intratracheal inoculation of 0.2 ml inoculum of Aspergillus fumigatus (CBS 113.26 strain) consisting of approximately 2.7 x 106 spores/ml. Two days after the inoculation, general clinical signs of aspergillosis in the respiratory tract were observed. In the histopathological examination, caseous foci were found in lungs, trachea and on airsacs. All quails died in the infected untreated group. Aspergillus fumigatus was isolated from the various organs of all dead quails. There was no significant change in serum aspartate aminotransferase (AST) and gamma-glutamyltransferase (GGT) activities in infected untreated birds compared with controls. However, alanine aminotransferase (ALT) activity, albumin and calcium levels, and albumin/globulin (A/G) ratio were lower while phosphorus and globulin levels were higher in the infected untreated group than in controls. Each quail in the infected treated group was given 10 mg/kg/day itraconazole via drinking water for 7 days immediately after the first clinical findings. Although all quails died in the infected untreated group, 41 quails survived in the itraconazole treatment group. Biochemical values also returned approximately to the control levels after the treatment. The conclusion was drawn that aspergillosis in the quails might cause economical losses because of high mortality. Oral itraconazole treatment of aspergillosis might lower the mortality rate in quails.

Position and growth of upper and lower tooth primordia in prenatal mouse--3D study.

The secondary palate formation in mouse has been associated with the period of fast growth of the mandible from embryonic days (ED) 13.0 to 16.0. During that time, the incisors and first molars develop from the bud to the bell stage. We investigated the position and growth of the tooth during prenatal elongation of the lower and upper jaws, and searched for the developmental stage when alignment of opposing teeth was achieved. Computer-aided 3D representations allowed us to represent the position of incisors and molars in the embryonic head from ED 13.5 to 18.0 on the basis of data obtained from histological sections. The atlas-hypophysis connection exhibited minimum change in length and orientation during the prenatal period, and thus was used as a reference line. The length of the teeth was calculated from 3D data. The upper first and second molars were longer than the lower ones. When viewed from the upper side, the upper and lower molar primordia were parallel from ED 13.5 to 15.0. During this period, the upper molars had a more lateral position than the lower ones. This situation was maintained in the anterior extremity of the first molars at later stages, while the posterior part of the upper and lower molar epithelia reached opposition in the medio-lateral direction from ED 16.0. The lower incisors exhibited an apparently backward position when compared to the upper incisors at earlier stages. However, the distance between the prospective anterior tips of the opposing incisors gradually decreased. The part of Meckel's cartilage associated with the lower dental quadrant elongated more than 3-fold from ED 13.5 to 18.0, and the lower jaw grew faster than the upper one. This difference resulted from the fast growth of the lower diastema from ED 14.0 to 18.0. The different growth speeds of the upper and lower jaws did not change the relative antero-posterior adjustment of the upper and lower molars, but contributed to achieving the opposition of the gnawing ends of the incisors.

Distribution of transforming growth factor beta1-binding proteins and low-affinity receptors during odontoblast differentiation in the mouse.

Transforming growth factor-beta1 (TGF-beta1) was immunolocalized within differentiated odontoblasts and ameloblasts while LAP-beta1 was detected at the apicol pole of odonotoblasts and ameloblasts and in predentine. Anti-LAP-beta1 antibodies also stained the epithelial-mesenchymal junction (EMJ). Decorin was immunolocalized in young functional odonotoblasts and in both predentine and dentine. Biglycan was similarly distributed but absent from dentine. Immunostaining with anti-latent TGF-beta1 binding protein-1 (LTBP-1) showed fibrillar structures located at the EMJ and between predontoblasts and odontoblasts; at older states staining was restricted to the dental papilla and sac. Thus differentiated odonotoblasts express TGF-beta1 and in a more restricted manner decorin, biglycan and LAP-beta1; it can be assumed that TGF-beta1 is able to interact with the three molecules present in predentine. Earlier, LTBP-1 and LAP-beta1, both present at the EMJ, may contribute to odontoblast differentiation.

[Neoplastic pulmonary embolism. An uncommon cause of acute respiratory distress with normal pulmonary radiography]. / L'embolie pulmonaire néoplasique. Une cause inhabituelle de détresse respiratoire aiguë avec radiographie pulmonaire normale.

The incidence of neoplastic pulmonary embolism is certainly underestimated Necroscopy series report figures varying from 2.9 to 26. The clinical manifestations are similar to those observed in cruoric pulmonary embolism. We report two cases of acute respiratory failure with normal chest X-ray in which the diagnosis was neoplastic pulmonary embolism. The difficulties encountered for diagnosis resulted from the diffuse microvascular nature of the lesions. Perfusion scintigraphy and Swan-Ganz catheterism can be contributive, but certain diagnosis requires pathology examination. Prognosis is very poor. Clinicians should be aware of this pathology and entertain the diagnosis in all cor pulmonale patients with acute respiratory failure and a normal chest X-ray.

Immunolocalization of acidic and basic fibroblast growth factors during mouse odontogenesis.

Acidic and basic fibroblast growth factors (aFGF and bFGF), are both known to bind to extracellular matrix components, particularly proteoheparin sulfates, and to regulate in vitro proliferation, differentiation and morphology of cells of neuroectodermal and mesodermal origins. Their patterns of distribution were studied during mouse odontogenesis by means of indirect immunofluorescence and immunoperoxidase histochemistry on frozen fixed sections and after Bouin's fixative and paraffin embedding. Localization of aFGF on frozen fixed sections was observed in the oral epithelium, dental lamina and oral mesenchyme (day-12 of gestation), the stellate reticulum and oral epithelium (day-14), the stratum intermedium and at the basal and apical poles of preameloblasts at bell stage. After birth aFGF epitopes were localized within the predentin-dentin area, the stratum intermedium and at the secretory pole of ameloblasts. There was no staining with anti-aFGF antibodies after Bouin's fixative and paraffin embedding. In contrast, using this protocol, intense stainings were found with anti-bFGF antibodies predominantly within dental and peridental basement membranes and mesenchyme: staining of the dental basement membranes was transient (bud and cap stage) and discontinuous; a preferential concentration of bFGF epitopes in the condensed dental mesenchyme of incisors (cap stage) and the dental papillae mesenchymal cells of molars (bell stage) was observed in the posterior and the cervical part of tooth germs. An intense immunostaining of the stellate reticulum with anti-bFGF antibodies was also found on paraffin sections from bud to bell stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunolocalization of transforming growth factor beta 1 and epidermal growth factor receptor epitopes in mouse incisors and molars with a demonstration of in vitro production of transforming activity.

Day-14 lower incisors and day-18 first lower molars of mouse embryos produced in vitro transforming activities for non-confluent NRK cells co-cultured in agar, and mitogenic activities for exponentially growing NRK and BHK cells. The patterns of distribution of TGF beta 1 and EGF receptor, both known to regulate cell proliferation, differentiation and transformation in vitro and suspected to play important roles in developmental processes, were studied during mouse odontogenesis by means of indirect immunofluorescence on fixed or frozen fixed sections. TGF beta 1 epitopes were detected in the stellate reticulum of day-13 to day-16 incisors and of molars from day-17 onwards. Dental mesenchyme of day-14 incisors and postnatal molars, and peridental mesenchyme of bud and cap stage molars and incisors were also stained by TGF beta 1 antibodies. EGF receptor was localized in the enamel organs of incisors and molars; the inner dental epithelium and later the outer dental epithelium rapidly became negative while the stellate reticulum remained stained. Incisor apical mesenchyme showed an intense reaction with EGF receptor antibodies after birth.

Stimulatory effect of transferrin on the proliferation of embryonic mouse molar pre-odontoblasts and pre-ameloblasts in organ culture.

The effects of transferrin on the proliferation kinetics of these cells from day-14 lower first molars, cultured for 2-6 days in a chemically defined medium supplemented with 5 and 50 micrograms/ml of human diferric transferrin, were studied. Transferrin stimulated the mitotic and [3H]-thymidine labelling indices. These data were correlated with immunolocalization of the transferrin receptor using indirect immunofluorescence and specific monoclonal antibodies. The presence of specific transferrin receptors in pre-odontoblasts and pre-ameloblasts, and in ameloblasts of older teeth (day-18 to day-21), was also assessed by indirect immunofluorescence and binding experiments using iodinated transferrin.

Immunohistochemical localization of type IV collagen in mouse tooth germ: an ultrastructural study.

Localization of type IV collagen was analyzed at the ultrastructural level in mouse embryonic molars by using a preembedding technique. Cryostat sections were incubated with type IV collagen antibody and then treated with the peroxidase-antiperoxidase complex. This antibody was visualized at the epithelio-mesenchymal interface. Labeling was intense and uniformly distributed throughout the basement membrane. However, it was mainly restricted to the lamina densa. No immunostaining was detectable in the lamina lucida but it was crossed by fine filaments that appeared as projections from the lamina densa to the epithelial cell plasma membrane. At the mesenchymal aspect of the basement membrane, projections of labeled material extended from the lamina densa in the underlying dental mesenchyme. At the presecretory stage of odontoblasts, these projections were in close connection with mesenchymal cell processes.

Epithelial-mesenchymal interactions: effects of a dental biomatrix on odontoblasts.

The functional differentiation of odontoblasts requires specific interactions between these cells and the extracellular matrix. To further analyze these phenomena we studied the effects of a "dental papillae biomatrix" on isolated dental papillae cultured in vitro. The dental papillae biomatrix was extracted from EDTA-dissociated day-18 mouse dental papillae by homogenization, NaCl and enzymatic treatments, and deposited on Millipore filters. This biomatrix was studied by means of transmission electron microscopy and indirect immunofluorescence: it contained collagen fibrils, type IV collagen, fibronectin and laminin; cellular residues were also observed. The dental papillae were isolated by trypsin treatment of homologous tooth germs and cultured on uncoated (control) and coated filters. As shown by histological and cytological data, odontoblast-like cells never differentiated in control cultures. In presence of biomatrix and serum, polarized functional cells were observed. The functional state of these cells was enhanced by the addition of ascorbic acid to the culture media. Study of the incorporation of 3H-proline in cultured dental papillae and in macromolecules secreted into the culture media corroborated the morphological findings.

Modifications of collagens in the course of inflammatory tracheal stenoses.

A comparison was made between the biochemical and histological properties of collagens contained in samples of normal tracheas obtained at autopsy or of stenosed tracheas obtained during surgery. The amounts of total collagen solubilized by pepsin was increased seven times in the pathological samples, and the proportion of cartilage type II collagen decreased by about one half, being replaced by type I collagen, whose ratio was increased five times. Microscopic studies confirmed that cartilage underwent a degenerative process and was progressively infiltrated by fibrils of interstitial collagen.

Immunohistochemical localisation of macromolecules of the basement membrane and extracellular matrix of human gliomas and meningiomas.

The distribution of type I, III, IV and V collagen in 35 gliomas and 20 meningiomas was studied by indirect immunofluorescence staining. In addition, the presence of fibronectin (FN) and laminin (LN) is also reported. In gliomas expression of type IV collagen and LN was found in the vessel walls and associated with the endothelial glomerulus-like proliferations. FN and type V collagens were located in proliferating vessel walls in a pattern corresponding both to the basement membrane and the perivascular matrix around the vessels. In the extracellular matrix of grade III and IV gliomas occasional faint intercellular fluorescence was also observed with both FN and type V collagen. Type I and III collagens were localised in the vessel walls and in the perivascular connective sheet. Glioma cells did not express any of the antigens investigated. In meningiomas, type IV and V collagens, LN and FN were found in vessel walls, whorls formations and psammoma bodies. These stainings support the hypothesis of a vascular origin of these psammoma bodies which were only found in syncytial and transitional meningiomas. Both type I and III collagens were detected in the perivascular connective tissue. In general, meningioma cells and extracellular matrix did not express any of these molecules, except in transitional meningiomas where occasional fluorescence was observed in extracellular matrix with type V collagen and FN.