Developing and paying for medicines for orphan indications in oncology: utilitarian regulation vs equitable care?

Despite 'orphan drug' legislation, bringing new medicines for rare diseases to market and securing funding for their provision is sometimes both costly and problematic, even in the case of medicines for very rare 'ultra orphan' oncological indications. In this paper difficulties surrounding the introduction of a new treatment for osteosarcoma exemplify the challenges that innovators can face. The implications of current policy debate on 'value-based' medicines pricing in Europe, North America and elsewhere are also explored in the context of sustaining research into and facilitating cancer patient access to medicines for low-prevalence indications. Tensions exist between utilitarian strategies aimed at optimising the welfare of the majority in the society and minority-interest-focused approaches to equitable care provision. Current regulatory and pricing strategies should be revisited with the objective of facilitating fair and timely drug supply to patients without sacrificing safety or overall affordability. Failures effectively to tackle the problems considered here could undermine public interests in developing better therapies for cancer patients.

Feral goats in Australia: A study on the quality and nutritive value of their meat.

The purpose of this study was to determine the quality of fresh and cooked meat, and the nutritive value of this meat from 62 male Australian feral goats. The goats were slaughtered at 5, 10, 20, 30, 40, 50, 60 and 70kg liveweights. Half of the goats were castrated and half were left as intact animals. The quality profiles of meat (e.g. pH, colour, pigment concentrations, cooking loss, shear force value and eating quality of cooked meat) from both castrated and intact feral goats started to decrease when animals were slaughtered at heavier liveweights (e.g. above 40kg). The nutritive value of the meat (chemical compositions, fatty acids and total cholesterol concentrations) changed when animals were castrated and had heavier slaughter weights. Overall, we recommend that 40kg liveweight is the heaviest slaughter weight, since the quality characteristics of meat will be lower when feral goats were slaughtered above 40kg liveweight.

Primal joints and hind-leg cuts of entire and castrated Javan rusa (Cervus timorensis russa) stags.

The effects of castration on the primal joints and the cuts of the leg joint of Javan rusa (Cervus timorensis russa) stag carcases was investigated at three slaughter ages (13, 19 and 25 months). Castration reduced the weights of some primal joints in the 19- and 25-months age groups, but not at 13 months. At 19 months, the neck, and neck plus chuck, were heavier by 35 and 17% respectively in entires (P<0.05), and at 25 months entires had heavier carcases, shoulder, forequarter and hindquarter (P<0.05). The leg and saddle joints were approximately 39 and 18% of the side, respectively, for both treatments and all ages. The proportions of the neck, and neck plus chuck, were higher (P<0.05) in 19-month old entires than castrates. There were few significant differences between treatments in the weight or proportion of the hind leg cuts at any slaughter age, but in the 25-months group the silverside was 8% (P<0.05) heavier in entires. In both castrates and entires, there appeared to be an increase in the percentage of the rump as the animals grew from 13 to 19 months of age.

Impaired distal airway development in mice lacking elastin.

Elastin is a major component of the mammalian lung, predominantly found in the alveoli. Destruction of alveolar elastic fibers is implicated in the pathogenic mechanism of emphysema in adults. These data define a role for elastin in the structure and function of the mature lung, and suggest that elastin is important for alveogenesis. To investigate the role of elastin in lung development, we examined mice lacking elastin (Eln-/-). At birth, the distal air sacs of Eln-/- lungs dilate to form abnormally large cavities. This phenotype appears before the synthesis and deposition of alveolar elastin, a process mediated by myofibroblasts and initiated after postnatal Day 4. Morphometric analyses demonstrate that the perinatal development of terminal airway branches is arrested in Eln-/- mice. The branching defect is accompanied by fewer distal air sacs that are dilated with attenuated tissue septae, a condition reminiscent of emphysema. Elastin expression in the lung parenchyma before alveogenesis is localized to the mesenchyme surrounding the developing airways, supporting a role for elastin in airway branching. Thus, in addition to its role in the structure and function of the mature lung, elastin is essential for pulmonary development and is important for terminal airway branching.

Mitogen-activated protein kinase regulates transcription of the ApoCIII gene. Involvement of the orphan nuclear receptor HNF4.

The transcriptional regulation of the apoCIII gene by hormonal and metabolic signals plays a significant role in determining plasma triglyceride levels. In the current work we demonstrate that the apoCIII gene is regulated by the mitogen-activated protein (MAP) kinase signaling pathway. In HepG2 cells, repression of MAP kinase activity by treatment with the mitogen-activated protein kinase/extracellular signal-regulated kinase kinase inhibitor PD98059 caused a 5-8-fold increase in apoCIII transcriptional activity. Activation of MAP kinase by phorbol ester treatment caused a 3-5-fold reduction in apoCIII transcription. The region of the apoCIII promoter responsible for this regulation was mapped in transiently transfected HepG2 cells to a 6-base pair element located at -740. The major protein binding to this site was identified as the nuclear hormone receptor HNF4. An increase in HNF4 mRNA and protein levels was observed in HepG2 cells after treatment with PD98059, indicating that the MAP kinase pathway regulates the expression of the HNF4 gene. These findings demonstrate that the apoCIII gene can be regulated by signals acting through the MAP kinase pathway and that this regulation is mediated, at least in part, by changes in the amount of HNF4.

Defective angiogenesis in mice lacking endoglin.

Endoglin is a transforming growth factor-beta (TGF-beta) binding protein expressed on the surface of endothelial cells. Loss-of-function mutations in the human endoglin gene ENG cause hereditary hemorrhagic telangiectasia (HHT1), a disease characterized by vascular malformations. Here it is shown that by gestational day 11.5, mice lacking endoglin die from defective vascular development. However, in contrast to mice lacking TGF-beta, vasculogenesis was unaffected. Loss of endoglin caused poor vascular smooth muscle development and arrested endothelial remodeling. These results demonstrate that endoglin is essential for angiogenesis and suggest a pathogenic mechanism for HHT1.

The influence of goat genotype on the production of Capretto and Chevon carcasses. 2. Meat quality.

The effect of five goat genotypes, Boer×Angora (BA), Boer×Saanen (BS), Feral×Feral (FF), Saanen x Angora (SA) and Saanen x Feral (SF) on the meat quality of Capretto and Chevon carcasses obtained from 50 buck kids, was assessed. Genotype had an influence on cooking loss and longissimus thoracis muscle colour coordinates (CIE L(*), a(*), b(*) values). BS kids from the Capretto group had paler muscle colour compared to other genotypes; pale muscle colour being required for Capretto carcasses. Total pigment concentration, fat colour, shear force values and sensory scores for flavour, tenderness, juiciness and overall acceptability did not differ significantly between genotypes. Muscle colour became darker and fat colour became more yellow with increasing animal age. Tenderness decreased with animal age as indicated by higher shear force values. Age had no significant influence on cooking loss and sensory scores.

The influence of goat genotype on the production of Capretto and Chevon carcasses. 1. Growth and carcass characteristics.

Fifty buck kids from five goat genotypes, Boer × Angora (BA), Boer × Saanen (BS), Feral × Feral (FF), Saanen × Angora (SA) and Saanen × Feral (SF) were compared for production of Capretto and Chevon carcasses. BS and SF kids had significantly better average daily gain compared to other genotypes and took less time to reach the required liveweight for Capretto and Chevon production. The development of visceral organs was not influenced by genotype. Kids from dairy breeds (SA in case of Capretto and SF in case of the Chevon group) deposited more internal fat in comparison to other genotypes. Dressing percentage (based on empty body weight) of kids ranged from 50-55%. At the same liveweight, dressing percentage and eye muscle dimensions did not vary between genotypes. However, BS and SF kids produced longer carcasses. Subcutaneous fat thickness was significantly greater in Chevon carcasses from BA compared to other genotypes. A high correlation was found between fat thickness measured by ultrasound on the live animal and ruler measurement on the carcass at the 12/13th rib position. Based on growth and carcass characteristics BS and SF kids performed better than kids from other genotypes used in the present study.

The influence of goat genotype on the production of Capretto and Chevon carcasses. 3. Dissected carcass composition.

The dissected composition from left sides of the carcasses obtained from 50 buck kids from five goat genotypes (10 kids/genotype), Boer x Angora (BA), Boer x Saanen (BS), Feral x Feral (FF), Saanen x Angora (SA) and Saanen x Feral (SF), was compared at two age groups. The muscle content of various primal cuts varied between 53 and 73% for Capretto and Chevon groups, with minor differences between genotypes. SA kids had significantly higher separable carcass fat compared to BS and SF for the Capretto group, while Chevon carcasses from BA and SF deposited more carcass fat than FF. The bone content (19-21%) of the carcass side did not differ significantly between genotypes for the Chevon group. The dissected carcass components (muscle, fat and bone) were significantly correlated with those components of most of the individual cuts. The percentage carcass muscle and fat increased and bone content decreased significantly with age.

The influence of goat genotype on the production of Capretto and Chevon carcasses. 4. Chemical composition of muscle and fatty acid profiles of adipose tissue.

The chemical composition of muscle and the fatty acid composition of adipose tissue from the carcasses obtained from 50 buck kids from five genotypes (10 kids/genotype), Boer x Angora (BA), Boer x Saanen (BS), Feral x Feral (FF), Saanen x Angora (SA) and Saanen x Feral (SF) reared for Capretto and Chevon production, were compared. Genotype did not influence the chemical composition of muscle except for muscle from BA carcasses, which had significantly higher extractable fat content. The proportions of individual fatty acids differed significantly between genotypes for the Capretto kids. Adipose tissue from the Capretto group had a higher concentration of palmitic acid (31-34%), while the proportion of oleic acid (37-40%) was greater in the Chevon group. With an increase in age and resultant change in diet, the saturated fatty acid concentration decreased and the unsaturated fatty acid concentration increased.

Novel arterial pathology in mice and humans hemizygous for elastin.

Obstructive vascular disease is an important health problem in the industrialized world. Through a series of molecular genetic studies, we demonstrated that loss-of-function mutations in one elastin allele cause an inherited obstructive arterial disease, supravalvular aortic stenosis (SVAS). To define the mechanism of elastin's effect, we generated mice hemizygous for the elastin gene (ELN +/-). Although ELN mRNA and protein were reduced by 50% in ELN +/- mice, arterial compliance at physiologic pressures was nearly normal. This discrepancy was explained by a paradoxical increase of 35% in the number of elastic lamellae and smooth muscle in ELN +/- arteries. Examination of humans with ELN hemizygosity revealed a 2. 5-fold increase in elastic lamellae and smooth muscle. Thus, ELN hemizygosity in mice and humans induces a compensatory increase in the number of rings of elastic lamellae and smooth muscle during arterial development. Humans are exquisitely sensitive to reduced ELN expression, developing profound arterial thickening and markedly increased risk of obstructive vascular disease.

Three isoforms of a hepatocyte nuclear factor-4 transcription factor with tissue- and stage-specific expression in the adult mosquito.

We cloned three isoforms of hepatocyte nuclear factor-4 (HNF-4) from the mosquito Aedes aegypti, designated AaHNF-4a, AaHNF-4b, and AaHNF-4c. AaHNF-4a and AaHNF-4b are typical members of the HNF-4 subfamily of nuclear receptors with high amino acid conservation. They differ in N-terminal regions and exhibit distinct developmental profiles in the female mosquito fat body, a metabolic tissue functionally analogous to the vertebrate liver. The AaHNF-4b mRNA is predominant during the previtellogenic and vitellogenic phases, while the AaHNF-4a mRNA is predominant during the termination phase of vitellogenesis, coinciding with the onset of lipogenesis. The third isoform, AaHNF-4c, lacks part of the A/B and the entire C (DNA-binding) domains. The AaHNF-4c transcript found in the fat body during the termination of vitellogenesis may serve as a transcriptional inhibitor. Both AaHNF-4a and AaHNF-4b bind to the cognate DNA recognition site in electrophoretic mobility shift assay. Dimerization of AaHNF-4c with other mosquito HNF-4 isoforms or with mammalian HNF-4 prevents binding to the HNF-4 response element. In transfected human 293T cells, AaHNF-4c significantly reduced the transactivating effect of the human HNF-4alpha1 on the apolipoprotein CIII promoter. Electrophoretic mobility shift assay confirmed the presence of HNF-4 binding sites upstream of A. aegypti vg and vcp, two yolk protein genes expressed in the female mosquito fat body during vitellogenesis. Therefore, HNF-4, an important regulator of liver-specific genes, plays a critical role in the insect fat body.

OKN, perceptual and VEP direction biases in strabismus.

The present study quantified nasalward/temporalward biases in monocular optokinetic nystagmus (MOKN) and perceived velocity in patients with either early onset esotropia, late onset esotropia and in normals. MOKN was measured with low spatial frequency, small-field gratings drifting at 9.4 degrees/s. MOKN bias was quantified as the ratio of nasalward slow-phase velocity divided by the sum of temporalward and nasalward slow-phase velocities (N/(N + T)). Observers also rated the perceived velocity of gratings moving in nasalward and temporalward directions (3 or 9.4 degrees/s) using a two interval forced choice task. MOKN and perceived velocity biases were correlated negatively in both early onset and late onset groups in the perceptual task--nasalward moving targets were rated as slower than temporalward targets, but in the MOKN task, slow-phase gain was higher for nasalward than for temporalward targets. Oscillatory-motion, visual evoked potentials (VEPs), were recorded in response to 1 c/deg gratings undergoing apparent motion at 10 Hz in a subset of the observers. VEP direction biases were quantified by calculating the ratio of first harmonic response amplitudes to the sum of first and second harmonic amplitudes. Significant correlations were found between the direction biases obtained on all three measures. Perceived velocity and MOKN bias measures were also correlated negatively. Patients with early onset esotropia (infantile esotropia) had larger biases than late onset esotropes or normals on each measure and the biases were more frequently bilateral in the early onset patients. The pattern of result is consistent with early critical periods for the mechanism(s) underlying MOKN, perceived velocity and cortical responsiveness. A single site model for all three asymmetries is unlikely, at least in simple form, because of the negative correlation between MOKN and perceived velocity biases and because of the differences in relative magnitude between the perceptual and MOKN biases.

Is stereopsis effective in breaking camouflage for moving targets?

It has been suggested that breaking camouflage is one of the major functions of stereopsis (Julesz, 1971). In this study, we found that stereopsis is less effective in breaking camouflage for moving targets than for static ones. Observers were asked to detect a single dot moving on a straight trajectory amidst identical noise dots in random motion. In the three-dimensional (3D) condition, the noise dots filled a cylindrical volume 5.7 cm in height and diameter; the trajectory signal dot moved on an oblique 3D trajectory through the center of the cylinder. In the two-dimensional (2D) control condition, observers viewed one half-image of the 3D cylinder binocularly. Surprisingly, trajectory detection in the 3D condition was only slightly better than in the 2D condition. Stereoscopic tuning for motion detection was also measured with a novel target configuration in which the random motion noise was presented in two depth planes that straddled the fixation plane where the trajectory target was presented. As the disparity between the noise planes and the fixation plane was increased, trajectory detection improved, reaching a peak between 6 and 12 arcmin, and then declining to the 2D level at larger disparities, where the noise became diplopic. Similar tuning measurements were made for detecting a static pattern, a string of five aligned dots presented in the fixation plane between two planes of static noise dots. Adding disparity to the noise planes produced a far greater improvement in static detection than in motion detection, for a comparable range of disparities (1.5-12 arcmin). We speculate that the temporal characteristics of the stereo system are not well suited for responding to moving targets, with the result that stereo does not greatly enhance motion detection in noise.

Use of surface-modifying macromolecules to enhance the biostability of segmented polyurethanes.

Polyurethanes are widely used as biomaterials for medical implants because of their excellent mechanical properties and moderate biocompatibility. However, the demand for more bioresistant and biocompatible polyurethanes to meet the needs of long-term implant devices still remains an important issue. Since most biological interactions with materials occur at the interface, a significant number of studies for improving the biocompatibility of polyurethanes have concentrated on surface modification. It is well known that additives used in polymeric materials as processing aids, mold releasing agents, antioxidants, etc., migrate to the surface and change the surface properties of the material. Under certain conditions polymeric additives may also migrate toward surfaces. This study describes two fluorine-containing, surface-modifying macromolecules (SMMs) that have been evaluated for their ability to inhibit polyurethane degradation. These materials actively migrate to the upper surface of a material film when they are mixed with a base polymeric materia. Contact angle measurements for the mixture of SMM with base polyurethane indicate that the surface becomes more hydrophobic after adding the SMMs, while X-ray photoelectron spectroscopy analysis shows an enrichment of fluorine on the polymer surfaces. Differential scanning calorimetry thermograms indicate that the micro-structure, as defined by the thermal transitions of the base polymer, are not altered by the addition of SMMs. Enzyme-induced biodegradation tests exhibit a significant reduction of polyurethane degradation in the presence of these surface-resident materials. The results indicate that the SMMs have the potential to resist hydrolytic degradation mediated by lysosomal enzymes while generating a surface chemistry on the native elastomer which is similar in nature to that of a fluoropolymer, e.g., Teflon.

Application of macromolecular additives to reduce the hydrolytic degradation of polyurethanes by lysosomal enzymes.

Of the various polymers used in medical devices, polyurethanes have been relatively successful because of their acceptable mechanical and biological properties. However, over the past decade, increasing concerns have arisen in relation to long-term biostability of polyurethanes when exposed to the harsh environment of the human body. Lysosomal enzymes released from inflammatory cells have been proposed to be important mediators in the degradation of biomedical polyurethanes. In order to increase the biostability of polyurethanes to lysosomal enzymes, a series of surface-modifying macromolecules (SMMs) were synthesized in this work and then combined into a base polyurethane to reduce the material's susceptibility to hydrolysis. X-ray photoelectron spectroscopy (XPS) studies showed that the SMMs were enriched within the upper 10 nm of the surface. In vitro biodegradation test results indicated that the degradation of a polyester-urea-urethane could be inhibited by the new SMM surface. It was also found that different SMM formulations provided varying degrees of inhibition against the biodegradation of the polyester-urea-urethane. Certain formulations of the SMMs were shown to be physically incompatible with the polyurethane and distorted surface morphology to the extent that biodegradation was enhanced.

Investigations into the accuracy of prediction of beef carcass composition using subcutaneous fat thickness and carcass weight II. Improving the accuracy of prediction.

Attempts were made to improve the accuracy of prediction of carcass components in 68 steer carcasses using a subcutaneous fat thickness measurement (FTP(8)) and hot side weight as the principal or sole predictors. When carcasses were divided into two weight ranges, prediction of the percentages of carcass fat (fat %) and muscle (muscle %) in the lighter group, using FTP(8), were almost as accurate (fat %: RSD, 1.83; R(2), 0.73; muscle %: RSD, 1.70; R(2), 0.47) as those given by multiple regression measurements made by advanced technologies. Prediction in the heavier weight group was unsatisfactory, featuring high RSDs and a low R(2). Because breed differences in prediction did not occur in the lighter group, a single prediction equation could be used for each carcass component. The use of fat thickness groups gave a similar result to that of weight groups. Once weight groups were used, curvilinear analysis did not improve the accuracy of prediction. In the lighter carcasses, the addition of hot side weight, eye muscle area and muscle score, singly or in combination, did not improve the accuracy of percentage predictions. In the heavier carcasses, the addition of hot side weight and eye muscle area was necessary to give prediction of a modest level of accuracy. For the prediction of the weights of carcass components, the addition of hot side weight to FTP(8) gave the most accurate prediction in light carcasses (fat weight: RSD, 1.60; R(2), 0.92; muscle weight: RSD, 2.08; R(2), 0.97). In the heavy carcasses, hot side weight and eye muscle area added to FTP(8) gave the most accurate prediction (fat weight: RSD, 4.40; R(2), 0.69; muscle weight: RSD, 3.73; R(2), 0.88). Because of the high level of variance explained, it is recommended that weights of carcass components be predicted, particularly in heavy carcasses.

Investigations into the accuracy of prediction of beef carcass composition using subcutaneous fat thickness and carcass weight I. Identifying problems.

Investigations were conducted into the accuracy of prediction of the percentages of fat and muscle in 69 steer carcasses using subcutaneous fat thickness and carcass weight. The carcasses were arbitrarily divided into low and high fat thickness, and light and heavy weight categories. Relationships between fat thickness and the percentages of fat and muscle were modified by breed and weight group (or their interactive effects), or by breed and fat group (or their interactive effects). General equations ignoring breed should not, therefore, be used for prediction. The equations were modified by using low and high fat thickness or light and heavy carcass weight groups. Because of the absence of breed differences in the lighter weight and lower fat thickness groups, a single breed-ignored regression equation could be used in each case to predict the carcass components. In the fatter and heavier groups of carcass significant breed differences occurred and breed specific regression equations should be used.

Characterization of a dominant negative mutant form of the HNF-4 orphan receptor.

The HNF-4 orphan receptor is a member of the nuclear receptor family of transcription factors and a major regulator of genes involved in carbohydrate and lipid metabolism. As an initial step in characterizing the role of HNF-4 in the regulation of metabolism, we have generated a dominant negative form of HNF-4 (DN-HNF-4) that contains a defective DNA-binding domain. In gel mobility shift assays, DN-HNF-4 did not bind an oligonucleotide probe representing an essential HNF-4 binding site, C3P contained in the human apo CIII promoter, but did prevent the binding of two recombinant isoforms, HNF-4alpha1 and HNF-4alpha2, as well as naturally-occurring HNF-4. DN-HNF-4 had no effect on the binding of PPARgamma-RXRalpha heterodimers to a PPAR response element. In transfected HepG2 cells, DN-HNF-4 dramatically reduced constitutive transcriptional activity of the human apo CIII promoter and abolished the positive transcriptional activity caused by plasmids expressing either isoform of HNF-4. These results indicate that DN-HNF-4 is a selective dominant negative mutant which forms defective heterodimers with wild-type HNF-4, thereby preventing DNA binding and subsequent transcriptional activation by HNF-4.