First, three meta-analyses confirmed that a high prevalence of JAK2 V617F mutation was observed in BCS and PVT patients, and routine screening for JAK2 V617F mutation was useful to diagnose the latent myeloproliferative neoplasms.[51-53] One of them further demonstrated that polycythemia

vera was clearly more common in BCS than in PVT.[53] Second, one meta-analysis confirmed that the prevalence of factor V Leiden mutation and factor II G202010A mutation were significantly higher in PVT patients with and without liver diseases than in controls.[54] Third, one recent meta-analysis demonstrated that the prevalence of inherited antithrombin, protein C and protein S deficiencies were significantly higher in non-cirrhotic patients with PVT than in healthy controls.[55] But the limited evidence did not show any association between these inherited deficiencies and BCS. Additionally, another meta-analysis did not support the relationship between antithrombin, Dabrafenib order protein C and protein S concentrations and the development of PVT in liver cirrhosis.[56] Generally, the results of these meta-analyses are helpful to determine the potential etiology of BCS and PVT and to establish the clinical necessity of screening for thrombotic risk factors in such patients.

However, to the best of our knowledge, no Enzalutamide cell line systematic review and meta-analysis has been conducted to explore selleck chemicals the role of MTHFR C667T mutation and homocysteine in BCS and

PVT patients. Our study showed the major following findings: (i) the prevalence of homozygous MTHFR C677T mutation was significantly higher in BCS patients than in healthy controls; (ii) the prevalence of homozygous MTHFR C677T mutation was higher in non-cirrhotic PVT patients than in healthy controls, but the difference was not statistically significant; (iii) BCS or non-cirrhotic PVT patients had a significantly higher prevalence of hyperhomocysteinemia and plasma homocysteine level than healthy controls, which potentially suggested that hyperhomocysteinemia may be a risk factor of BCS and non-cirrhotic PVT; and (iv) compared with those without PVT, cirrhotic patients with PVT had a significantly higher prevalence of homozygous MTHFR mutation, but a similar prevalence of heterozygous MTHFR C667T mutation, which indicated that MTHFR C667T mutation in a homozygous trait may contribute to the pathogenesis of PVT in liver cirrhosis. An early meta-analysis of nine studies demonstrated a significantly increased risk of venous thromboembolism in patients with elevated plasma homocysteine levels.[7] Subsequently, their meta-analysis of 31 studies showed a statistically significant difference in the prevalence of MTHFR 677TT genotype between patients with venous thromboembolism and controls.[57] However, considering that the trend towards an increasing risk of venous thromboembolism in such patients was weak (OR = 1.

At the initial outpatient office visit 2 months after her emergency room presentation, the patient remained headache-free. When pressed for family history,

the patient stated that her mother had “white stuff in the brain,” suffered from frequent headaches, depression, and had recently been evaluated for cognitive decline. She also recalled that her maternal grandmother had suffered from dementia with onset after age 80. As her longitudinal clinical course and neuroimaging were suggestive of CADASIL, genetic testing for neurogenic locus notch homolog protein 3 (NOTCH3) gene was obtained. She tested positive for a deoxyribonucleic acid sequence alteration in the NOTCH3 gene located on the short arm of chromosome 19 that has been reported as a CADASIL-associated mutation. CADASIL is the Pirfenidone solubility dmso most common heritable cause of stroke and vascular dementia in adults, accounting for 2% of cases of lacunar stroke and leukoaraoisis in patients younger than 65 years and for 11.1% of cases in patients younger than 50 years.[22, 23] The overall prevalence is not well known. A small study from Scotland estimated that 4.14/100,000 cases were predicted mutation carriers and 1.98/100,000 cases have the definitive diagnosis.[24] Another www.selleckchem.com/products/Adriamycin.html small study from western England provided similar results, estimating the minimum prevalence of definite cases as 1.32/100,000,

and the minimum prevalence of mutation carriers to be 4.10/100,000.[25] The prevalence may be higher, however, as sporadic cases have been reported.[26] Additionally, there is marked intrafamilial phenotypic variability, which may lead to under recognition of this disorder.[27] Although the clinical presentation of CADASIL can vary widely, it is characterized by 4 main symptoms: migraine with aura, subcortical

ischemic events, mood disturbance, and cognitive impairment. The most frequent initial symptoms include migraine with aura and subcortical ischemic events. Symptom onset is typically in the fourth or fifth decade of life, but when the presenting symptom is migraine with aura, the age of onset is often younger, often in the third decade of life.27-29 There may be a gender difference in symptom expression in CADASIL patients, see more with migraine with aura being more prevalent in women and stroke being more prevalent in men younger than 51 years, a difference that seems to subsequently disappear in older patients. Age at first stroke, the number of stroke events, and the prevalence of dementia and psychiatric symptoms, however, does not seem to differ between men and women.[30] As exhibited by our patient, pregnancy and the puerperium appear to be a particularly vulnerable time for manifestation of neurological symptoms in CADASIL patients, and many patients may have their initial manifestation of CADASIL during this period.

In addition, since NO is known to have dual cytoprotective and cytotoxic effects within tissues, LBH589 datasheet depending on the gas level, determination of the NO level is required to evaluate its function in tissues. We developed an animal model in which high concentrations

of NO were generated luminally at the GE junction by co-administration of physiological concentrations of nitrite plus ascorbic acid.[27] In this study, because NO is an unstable free radical in tissues, an Fe-diethyldithiocarbamate complex was employed as a trapping agent to form a relatively stable radical adduct.[28] Then, the concentration of NO in the gastric tissue of rats was measured by quantifying the resultant radical adduct using electron paramagnetic resonance spectroscopy.[28] In the rat model, the high level of exogenously derived NO detected in the mucosal layer at the GE junction of nitrite-administered rats was at a level comparable click here with the level of endogenously derived NO from iNOS.[27] Meanwhile, exogenous NO affected some important cell functions in the adjacent tissue, including NO consumption of glutathione, a major antioxidant in the protection against cell damage,[27] and/or NO inhibition

of mitochondrial aconitase, an important enzyme for cell respiration.[29] These results from animal model studies indicate that exogenous NO can induce cytotoxic effects in living cells in adjacent tissues. In addition, by employing a unique endogenous characteristic signal comprised of NO-mediated degradation of iron–sulfur cluster-containing proteins, we also confirmed that diffusion of NO from the lumen into the adjacent tissue could occur in humans as well.[29] The majority of salivary nitrite is rapidly converted to NO at the human GE junction, and the gas rapidly diffuses into the adjacent epithelium; therefore, only a small amount of nitrite is left in the more distal stomach.[30] Accordingly, luminal concentrations of NO in the distal stomach become even lower compared with those at the GE junction.[10, 25] Since NO has dual effects on the tissue depending on find more the level of the

gas,[31, 32] a relatively low concentration of NO, as seen in the distal stomach, could function as a protective mediator to maintain the gastric mucosal integrity.[19] In contrast, a high cytotoxic concentration of local NO at the gastric cardia may be involved in the pathology of mucosal injury at that site.[11] In fact, intragastric topical application or parental administration of NO is reported to have some beneficial effects on the stomach.[33-35] Because exogenous NO arises from an acidic lumen and diffuses into the adjacent tissue at the GE junction, the surface of the epithelium at the GE junction is exposed to the highest concentration of exogenous NO. Employing an ex vivo chamber system, we have demonstrated that luminal NO impairs the adjacent gastric barrier function primarily by disrupting the tight junction of the surface epithelium.

After surgery, the patient had significant abdominal pain with an elevated serum amylase and subsequently developed a large fluid collection in the right upper quadrant. The bile-stained fluid collection was drained percutaneously and fluid biochemistry showed both an elevated bilirubin PD98059 datasheet (19.3 mg/dL) and an elevated amylase (2481 U/L). The suspected bile leak was investigated by endoscopic retrograde

cholangiopancreatography and confirmed the anomalous pancreaticobiliary junction, the relatively narrow lower bile duct, and the choledochal cyst (Figure 2). The bile leak resolved after biliary sphincterotomy and placement of a biliary stent. An anomalous pancreaticobiliary junction is a rare congenital Selleck KPT330 anomaly where the distal bile duct and main pancreatic duct have a long common channel (>15 mm). In most patients, the long common channel extends outside the duodenal wall. Various radiological subtypes have been described but the most common are the apparent insertion of the bile duct into the main pancreatic duct (type I) and the reverse appearance (type II). In some patients, the common channel is dilated and there is a strong association with choledochal cysts. The anomaly is asymptomatic in some patients but others

have relapsing pancreatitis, chronic pancreatitis and complicated gallstones. There is also an association with gallbladder cancer, particularly in Japan. In case reports, several patients with gallbladder cancer have been younger women, often without gallstones. Reasons for the association between an anomalous pancreaticobiliary junction and gallbladder cancer remain unclear but one possibility is promotion

of carcinogenesis by find more the excessive reflux of pancreatic juice into the gallbladder. “
“Herker E, Harris C, Hernandez C, Carpentier A, Kaehlcke K, Rosenberg AR, et al. Efficient hepatitis C virus particle formation requires diacyl-glycerol acyltransferase-1. Nat Med 2010;16:1295-1298. Available at: www.nature.com/nm (Reprinted with permission.) Hepatitis C virus (HCV) infection is closely tied to the lipid metabolism of liver cells. Here we identify the triglyceride-synthesizing enzyme diacylglycerol acyltransferase-1 (DGAT1) as a key host factor for HCV infection. DGAT1 interacts with the viral nucleocapsid core and is required for the trafficking of core to lipid droplets. Inhibition of DGAT1 activity or RNAi-mediated knockdown of DGAT1 severely impairs infectious virion production, implicating DGAT1 as a new target for antiviral therapy. Hepatitis C virus (HCV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma worldwide. An important clinical hallmark of chronic HCV infection is its link with lipid biosynthesis and metabolism. Liver steatosis is frequently observed in HCV infection, and HCV has been implicated in the pathogenesis of steatosis.

After surgery, the patient had significant abdominal pain with an elevated serum amylase and subsequently developed a large fluid collection in the right upper quadrant. The bile-stained fluid collection was drained percutaneously and fluid biochemistry showed both an elevated bilirubin selleck products (19.3 mg/dL) and an elevated amylase (2481 U/L). The suspected bile leak was investigated by endoscopic retrograde

cholangiopancreatography and confirmed the anomalous pancreaticobiliary junction, the relatively narrow lower bile duct, and the choledochal cyst (Figure 2). The bile leak resolved after biliary sphincterotomy and placement of a biliary stent. An anomalous pancreaticobiliary junction is a rare congenital learn more anomaly where the distal bile duct and main pancreatic duct have a long common channel (>15 mm). In most patients, the long common channel extends outside the duodenal wall. Various radiological subtypes have been described but the most common are the apparent insertion of the bile duct into the main pancreatic duct (type I) and the reverse appearance (type II). In some patients, the common channel is dilated and there is a strong association with choledochal cysts. The anomaly is asymptomatic in some patients but others

have relapsing pancreatitis, chronic pancreatitis and complicated gallstones. There is also an association with gallbladder cancer, particularly in Japan. In case reports, several patients with gallbladder cancer have been younger women, often without gallstones. Reasons for the association between an anomalous pancreaticobiliary junction and gallbladder cancer remain unclear but one possibility is promotion

of carcinogenesis by see more the excessive reflux of pancreatic juice into the gallbladder. “
“Herker E, Harris C, Hernandez C, Carpentier A, Kaehlcke K, Rosenberg AR, et al. Efficient hepatitis C virus particle formation requires diacyl-glycerol acyltransferase-1. Nat Med 2010;16:1295-1298. Available at: www.nature.com/nm (Reprinted with permission.) Hepatitis C virus (HCV) infection is closely tied to the lipid metabolism of liver cells. Here we identify the triglyceride-synthesizing enzyme diacylglycerol acyltransferase-1 (DGAT1) as a key host factor for HCV infection. DGAT1 interacts with the viral nucleocapsid core and is required for the trafficking of core to lipid droplets. Inhibition of DGAT1 activity or RNAi-mediated knockdown of DGAT1 severely impairs infectious virion production, implicating DGAT1 as a new target for antiviral therapy. Hepatitis C virus (HCV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma worldwide. An important clinical hallmark of chronic HCV infection is its link with lipid biosynthesis and metabolism. Liver steatosis is frequently observed in HCV infection, and HCV has been implicated in the pathogenesis of steatosis.

28 ml /kg every two days;WenYuJin with low dose group were cheated by oral gavage administration of WenYuJin alcohol extract at dose of 1.4 g/kg every day,WenYuJin with high dose group were cheated by oral gavage administration selleck products of WenYuJin alcohol extract at dose of 2.8 g/kg every day,WenYuJin with low doses associated vincristine group were oral gavaged of WenYuJin alcohol extract at dose of 1.4 g/kg every day and intraperitoneally administered vincristine at dose of 0.28 ml /kg every two days;WenYuJin with high doses associated vincristine group were oral gavaged administration of WenYuJin alcohol extract at dose of 2.8 g/kg every

day and intraperitoneally administered vincristine at dose of 0.28 ml /kg every two days,with a total experiment period of 14 days. The next day after the last treatment, we killed the nude mice by taking off the cervical spine,cut tumors and weighed them, calculated the tumor inhibition Rucaparib molecular weight rate, saved the tumor specimens for detecting the expression of GCS by PCR, Western Blot and immunohistochemical. Results: 1. Tumor weight and tumor inhibition rate: WenYujin with high dose associated vincristine group was obviously

lighter than model group and vincristine, its tumor inhibition rate was 59.28%, tumor weight were respectively 0.283 ± 0.118, 0.695 ± 0.269, 0.592 ± 0.311, P < 0.05; WenYuJin with low doses associated vincristine group had no significantly differences compared with model group and vincristine group, (P > 0.05), and its tumor inhibition rate was 39.14%;the tumor

weight of WenYuJin group were 0.517 ± 0.309, 0.477 ± 0.119, they had no significantly differences compared with model group and vincristine group(P > 0.05),and between the two groups, they also had no significant difference (P > 0.05). 2. GCS mRNA expression in the PCR: The GCS mRNA expression of vincristine were significantly higher than the model group (2.39 ± 0.39, 1.44 ± 0.28, P < 0.05); WenYuJin with high dose group and WenYuJin associated vincristine were significantly lower than click here the model group, (1.11 ± 0.13, 1.02 ± 0.34, 0.74 ± 0.23, 1.44 ± 0.28, P < 0.05), However, the comparison between WenYuJin associated vincristine groups, there was no statistically significant difference (P > 0.05); and there was no statistically significant difference between WenYuJin with low dose group and model group (P > 0.05). 3. Wester blot: GCS protein expression in vincristine group were significantly higher than the model group (1.84 ± 0.18, 1.24 ± 0.06, P < 0.05); WenYuJin with high dose group and WenYuJin associated vincristine were significantly lower than the model group, (0.88 ± 0.17, 0.54 ± 0.04, 0.50 ± 0.06, 1.24 ± 0.06, P < 0.05), However, the comparison between WenYuJin associated vincristine groups, there was no statistically significant difference (P > 0.

28 ml /kg every two days;WenYuJin with low dose group were cheated by oral gavage administration of WenYuJin alcohol extract at dose of 1.4 g/kg every day,WenYuJin with high dose group were cheated by oral gavage administration Small molecule library chemical structure of WenYuJin alcohol extract at dose of 2.8 g/kg every day,WenYuJin with low doses associated vincristine group were oral gavaged of WenYuJin alcohol extract at dose of 1.4 g/kg every day and intraperitoneally administered vincristine at dose of 0.28 ml /kg every two days;WenYuJin with high doses associated vincristine group were oral gavaged administration of WenYuJin alcohol extract at dose of 2.8 g/kg every

day and intraperitoneally administered vincristine at dose of 0.28 ml /kg every two days,with a total experiment period of 14 days. The next day after the last treatment, we killed the nude mice by taking off the cervical spine,cut tumors and weighed them, calculated the tumor inhibition Daporinad nmr rate, saved the tumor specimens for detecting the expression of GCS by PCR, Western Blot and immunohistochemical. Results: 1. Tumor weight and tumor inhibition rate: WenYujin with high dose associated vincristine group was obviously

lighter than model group and vincristine, its tumor inhibition rate was 59.28%, tumor weight were respectively 0.283 ± 0.118, 0.695 ± 0.269, 0.592 ± 0.311, P < 0.05; WenYuJin with low doses associated vincristine group had no significantly differences compared with model group and vincristine group, (P > 0.05), and its tumor inhibition rate was 39.14%;the tumor

weight of WenYuJin group were 0.517 ± 0.309, 0.477 ± 0.119, they had no significantly differences compared with model group and vincristine group(P > 0.05),and between the two groups, they also had no significant difference (P > 0.05). 2. GCS mRNA expression in the PCR: The GCS mRNA expression of vincristine were significantly higher than the model group (2.39 ± 0.39, 1.44 ± 0.28, P < 0.05); WenYuJin with high dose group and WenYuJin associated vincristine were significantly lower than see more the model group, (1.11 ± 0.13, 1.02 ± 0.34, 0.74 ± 0.23, 1.44 ± 0.28, P < 0.05), However, the comparison between WenYuJin associated vincristine groups, there was no statistically significant difference (P > 0.05); and there was no statistically significant difference between WenYuJin with low dose group and model group (P > 0.05). 3. Wester blot: GCS protein expression in vincristine group were significantly higher than the model group (1.84 ± 0.18, 1.24 ± 0.06, P < 0.05); WenYuJin with high dose group and WenYuJin associated vincristine were significantly lower than the model group, (0.88 ± 0.17, 0.54 ± 0.04, 0.50 ± 0.06, 1.24 ± 0.06, P < 0.05), However, the comparison between WenYuJin associated vincristine groups, there was no statistically significant difference (P > 0.

Therapy against HCV infection was prescribed according to the caring physician criteria, based on consensus recommendations in effect along the study period, usually guided by HCV genotype and liver fibrosis stage. End-of-treatment response (ETR) was defined as undetectable serum HCV RNA at the planned date of treatment cessation. Sustained virological ACP-196 mouse response (SVR) was defined as undetectable serum HCV RNA 24 weeks after the end of treatment. Liver steatosis and liver fibrosis were scored blindly by a central pathologist (M.A.J.). HS classification was based on the proportion of hepatocytes containing fat droplets using Brunt’s criteria18 and was classified as

follows: 0, absent steatosis; 1, less than 33% (i.e., mild HS); 2, 33%-66% (i.e., moderate HS); and 3, more than 66% (i.e., severe HS). Lobular inflammation was scored as follows: 0 = no foci; 1 = <2 foci (excludes 2 foci ×200 field); learn more 2 = 2-4 (includes 2 and 4 foci ×200 field) 3 = >4 foci (excludes 4

foci ×200 field). Cytologic ballooning was classified as follows: 0, none; 1, few balloon cells; and 2, many cells/prominent ballooning. The NAFLD activity score (NAS) was calculated as the unweighted sum of steatosis, lobular inflammation, and hepatocellular ballooning scores.19 Scheuer’s score20 was applied to stage fibrosis as follows: 0, absent fibrosis; 1, portal fibrotic expansion; 2, extension of fibrosis to the lobule, but with few septa; 3, bridging fibrosis with numerous septa, with architectural distortion without cirrhosis; and 4, cirrhosis. The length of biopsies was recorded to assess their adequacy. The median (interquartile range; IQR) length of the initial biopsy was 17 (15-25) mm, whereas the respective figure of the second biopsy was 18 (16-25) mm. The primary outcome variable of the study was the progression in one or more grades in Brunt’s score. The associations of the following baseline factors with HS progression were analyzed: gender, age, body mass index (BMI), self-reported

selleck daily alcohol intake, diagnosis of diabetes mellitus (DM) following the American Diabetes Association criteria, fasting plasma glucose (FPG), cholesterol and triglycerides (TGs), HCV genotype, and Centers for Disease Control and Prevention (CDC) stage C. In addition, the following variables between biopsies and their relationship with HS progression were assessed: BMI, self-reported daily alcohol intake, FPG, cholesterol and TGs, response to treatment against HCV, CD4 cell counts at liver biopsies, plasma HIV RNA viral load at liver biopsies, exposure to ART, and changes in fibrosis stage. Cumulative exposure to individual antiretroviral drugs was calculated as the period in years receiving each antiretroviral drug between biopsies. Blood tests were drawn within 1 month before the liver biopsies. The secondary outcome variable was persistence of steatohepatitis between biopsies or progression to steatohepatitis in the final biopsy.

9, 10 Brewer9 recently analyzed why vitamin E is ineffective for the treatment of AD, and the reasons, including inappropriate

doses, inappropriate timing, and unbalanced monotherapy in the trials, were presumed. In addition, Steinhubl10 provided several possibilities for the negative trials of vitamin E in atherosclerosis, such as the wrong form of vitamin E (a synthetic form instead of a natural form comprising eight different isoforms used in the trials), inadequate durations, and the wrong patients. All these aspects should be taken into account when rigorous trials of vitamin E in WD are conducted. In addition, the rational suggestions proposed by Lu4 for the antioxidant selleck chemicals llc treatment of chronic liver diseases have important implications for future trials of vitamin E in WD. Liang Shen Ph.D.*, Hong-Fang Ji Ph.D.*, * Shandong Provincial selleck Research Center for Bioinformatic Engineering and Technique, Shandong University of Technology, Zibo, People’s Republic of China. “
“Drug-induced liver injury is one of the more challenging forms of liver disease, both in diagnosis and management. Several hundred drugs, nutritional supplements, and herbal medications have been implicated in causing liver injury. Their clinical presentation can be highly variable and mimic almost any form of liver disease. The literature on drug-induced

liver injury is large, but spread among many journals in many different specialties and languages. Excellent textbooks are available, but they are rapidly out-of-date and not always easily accessed. Drug-induced

liver injury is also a challenging area of research, in that most cases are unpredictable, idiosyncratic, and rare and thus difficult to study. As a consequence, there have been few advances in the understanding, control, or prevention of drug-induced liver injury selleck chemical in the last 50 years. DILIN, Drug-Induced Liver Injury Network; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NLM, National Library of Medicine. As a part of a long-term initiative in promoting basic and clinical research on drug-induced liver injury, the Liver Disease Research Branch of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in collaboration with the National Library of Medicine (NLM) has created the LiverTox website (www.livertox.nih.gov) (Fig. 1). LiverTox is a multilayered, informational, and interactive website with comprehensive and evidence-based information on drug, dietary supplement, and herbal-induced liver injury that is freely accessible to physicians, researchers, and the public. The website is particularly designed for use by physicians and healthcare professionals who might rarely see patients with drug-induced liver injury, including family practitioners, internists, pediatricians, psychiatrists, surgeons, specialists, and subspecialists in all areas of medicine.

The technology, knowledge and capacity exist to dramatically improve IDH inhibitor cancer global access to CFCs, it is now a moral imperative for governments, payers and industry to rise to the challenge by improving market accessibility, reducing reimbursement barriers, and adopting market-based business solutions to achieve it. Recent experience with a Health Technology Assessment (HTA) in Sweden and advancement of HTAs and similar tools such

as Comparative Effectiveness Research in other countries underscores the importance of outcomes analysis to support the high cost of present day treatment practices. There is an on-going need for additional research, outcomes analysis and evidence. The Swedish HTA concluded, in part, that the scientific evidence is insufficient to determine if there are any differences in effects between different dosing strategies or to determine which dosing strategy, i.e., on-demand or prophylaxis, is the most cost-effective in treating haemophilia [45,46]. Readers should not interpret click here this to mean prophylaxis is not the appropriate clinical decision; rather it means that the level of graded evidence to assess cost-effectiveness is not always of the highest level and, perhaps out of necessity, is often based on best clinical practice. Given the well-documented

outcomes of current clinical practice, randomized controlled studies to obtain additional evidence would be considered unethical in many countries today. Thus, fresh approaches to confront such assessments and to advance care beyond current levels are required. Assessment of treatment interventions for rare diseases such as haemophilia should not be confined to traditional analysis. Ranking haemophilia related interventions with standard interventions of therapeutics and public health in Cost Utility Analysis comparisons is inappropriate. They should be assessed with new methodologies specific to the disease see more and take into consideration societal willingness to support people with rare diseases [47]. Given bleeding frequency is one of the most important outcome

measures, greater emphasis and understanding of concepts such as the cost savings for a bleed prevented need to be integrated into our analysis. Following from this and the Swedish HTA, a novel cost-utility model for the assessment of the cost-effectiveness of prophylaxis to treat haemophilia has been proposed taking into account other variables in the equation such as reductions in the incidence of inhibitors, co-morbidities other than joint bleeds, and quality of life [48]. Emerging therapeutic advances should not be justified or brought to market based only on the notion that they will be economically more affordable, although that may be the case, but rather more importantly that they will be therapeutically more advantageous.