This paper explores the evolution of the driving forces that shape individual subjective well-being (SWB) in Spain from 2013 to 2018. Several socio-demographic, material conditions and quality of life (QoL) variables are considered as potential drivers of SWB. The data come from a large survey carried in two different time periods. The first one (2013) is characterized by a negative economic scenario as a result of the global financial crisis of 2008. The second one (2018) is characterized by fast economic recovery. Our results suggest that the material conditions variables, especially unemployment, have a much deeper impact on SWB during economic downturns than during economic recovery periods. Social connections and health status are determinant factors behind SWB, especially if the economy is working well. Our results also point to changes in gender effects. While women were happier than men in 2013, this effect disappears in 2018. Paradoxically, this suggest an increase in female expectations about their own lives during this period. The search for happiness is an old aspiration of human beings. More than 2300 years ago, the ancient Greeks were already discussing seriously about the nature of happiness and the paths to achieve it. Aristotle illustrated the importance of happiness and well-being for human development: “Happiness is the meaning and purpose of life, the general and final goal of human existence.” Recent times have witnessed the renaissance of happiness centrality in policy. Even the Davos’ 2019 World Economic Forum dedicated a special section to happiness and well-being. In one of the sessions, New Zealand Prime Minister Jacinda Ardern expressed with clarity the central role of the topic: “We need to address the societal well-being of our nation, not just the economic well-being.”The limitations of traditional income measures as indicators of social progress, has led to a search for new concepts that represent more accurately the goals of society. There are many international initiatives aimed at measuring happiness in order to quantify social progress and encourage governments to use this information to implement policies that can have an impact on people’s lives. Among the most influential, we may highlight the OECD’s Better Life Index, the World Database of Happiness or the Happy Planet Index, among others. One of the most influential is the Better Life Index (BLI), which compares well-being across countries, focusing on 11 dimensions of life that the OECD qualify as critical. These include quality of life (QoL) and material conditions variables that condition life.The modern academic interest in the discipline of happiness has evolved around the generic notion of subjective well-being (SWB). The literature often uses the terms SWB, QoL, Life Satisfaction and Happiness interchangeably, which reflects certain overlap between these concepts at both theoretical and empirical levels. However, notable differences exist, mainly with respect to SWB and QoL. Less attention has been paid to studying the time evolution of SWB in a population. External shocks (such as economic crises or pandemic conditions) may have notable effects not only on the levels of SWB but also on the elements that configure SWB itself. The 2008 economic crisis had a profound economic impact on the financial situation of large parts of the population. It also brought emotional suffering from facing sudden and unexpected changes, which may have an effect over mental models of happiness. For instance, unemployment is a factor that affects SWB very negatively. However, the way this variable affects SWB in a scenario of deep economic crisis may be much more severe than the way it does in a growing economic scenario. It is the same variable, but the expectations and emotional implications it brings may be completely different . On the The aim of this work is to examine which factors have been the main drivers of individual SWB in Spain over the period 2013–2018 and to explore the changes in the importance of the different driving forces over time. In doing so, we follow the definition of well-being elaborated by the OECD in the BLI project . The BLI1. Our view is that this effect is not independent of the overall level of unemployment. This is, being unemployed in a crisis scenario is much worse for SWB than in a recovery scenario. The first set of data available for this study comes from year 2013 in which Spain was still suffering the severe impact of an economic recession that hit the world since 2008. The prospects of economic recovery seemed remote then. Global macroeconomic factors  will have an impact on the way SWB is obtained at the individual level, with QoL variables, especially personal relationships and health, being moderating factors . In periAcademic analysis of SWB has focused on knowing the reasons why people feel satisfied or dissatisfied with their lives. While individual perceptions of life may have a genetic base, are subjective and unique to each person, research points to certain measurable factors that have substantial effects on SWB . Wilson Most studies find income as having a favorable impact on the level of satisfaction with life of individuals , althougAdditionally, comparisons introduce another important moderating factor for income. Both comparisons with other people belonging to the same social group  and comparisons with oneself in the past (habituation). At the same time, the link between education and happiness is equally vague. While education could increase SWB because it prepares individuals to better manage and deal with environmental situations, it could also raise aspiration levels, thus decreasing happiness . Some stThe three variables involved in HDI are to some extent interrelated. People with education and studies tend to obtain better employment and better health habits. In turn, people with greater wealth invest much more in education and personal health. Likewise, a healthier person is more likely to find better jobs and a higher level of education. For these reasons, the individual and separate effect of each of these variables on SWB becomes difficult to identify. In addition, important indirect effects may exist among these variables. For example, some studies have found significant indirect effects of education on SWBs due to their effect on health .Although income, education, and health are the main drivers of SWB, the list of variables that to a greater or lesser extent have an effect on SWB is much wider. The OECD’s Better Life Index provides a very comprehensive description that distinguishes a first set of material conditions variables from a second set of QoL variables. According to this proposal, the material conditions are represented by income and wealth, jobs and earning, and housing. In turn, the list of quality of life variables includes health status, work-life balance, education and skills, social connections, civic participation and governance, environmental quality, and personal safety.Therefore, some important dimensions of life can be added to the well-known HDI triad of income, education and health. In terms of material conditions, jobs and earnings (a dimension related to unemployment) and housing add important facets to income and wealth. With respect to QoL variables, the BLI adds work-life balance, social connections, civic engagement and governance, environmental quality and personal security to health and education. As noted above, the employed are happier and more satisfied with their lives than the unemployed, although the number of hours worked also influences the SWB. Civic engagement, including involvement and participation within the community, has consistently shown a beneficial effect on SWB . With reScholars have long noted the beneficial contribution of close social connections to SWB . SocialiAlthough the evidence in the literature is not very extensive, the quality of the environment has also been positively associated with SWB  and happIn addition to material conditions and QoL variables, demographic characteristics may also be important determinants of SWB. With regards to gender, an early meta-analysis conducted by The time evolution of SWB depends to a great extent on the evolution of its driving forces. Therefore, improvements in material conditions and quality of life variables should be accompanied by an increase in SWB. Looking at the individual level, some variables can change very quickly, while others cannot. For example, an individual may lose the job and become unemployed from one day to another. Health status may also deteriorate on time or improve quickly after receiving treatment from an illness. Other variables operate only in one direction. Education is the most notable, since you can only go forward. Within these limits, the expectation is that the evolution in the level of SWB may relate to the evolution in the levels of its driving forces.However, the manner in which the different driving forces affect the level of SWB may also evolve on time. External events may change the way individuals perceive the effects of their personal situation concerning those forces. The financial crisis that shook the world in 2008 provides an opportunity to check these variations in the weights attached to the different dimensions that make a good or a bad living. A large portion of the population personally suffered the effects of the crisis during the years after 2008. Some lost their jobs, other lost their houses (houses they could no longer afford) or found no finance for their housing prospects. Under these circumstances, it is reasonable to expect that income, housing and unemployment, i.e., the material conditions variables, would play a central role in the way the individual perceives SWB.But the well-known Easterlin paradox  points tAdditionally, social connections may have a moderating effect on SWB in periods of economic downturn, through the instrumental support of friends and family when searching for job opportunities or obtaining financial support. Moreover, social connections bring emotional support and a sense of belonging that helps maintaining the levels of SWB . Social The data comes from the annual survey on living conditions in Spain, elaborated by the Spanish National Institute of Statistics (INE) for the years 2013 and 2018. We took these years, because they are the only ones that contain a supplementary module with information on well-being. Indeed, INE introduced the well-being module in the 2013 survey and is including it again every 5 years. This circumstance provides a unique opportunity to compare the evolution of SWB over time on a large dataset. The target population includes both households and individuals, with a sample size around 13,000 households and 35,000 individuals. These individuals are selected through a two-stage stratified sampling method and then, interviewed in person. Unfortunately, the data does not constitute a panel, since the respondents are different in 2013 and 2018. The reason is that 25% of sample respondents are replaced every year. Therefore, every 4 years, the sample is completely renewed.The dependent variable is the usual Satisfaction with Life scale, which reports the individual’s level of satisfaction with current life from 0 to 10. As for the drivers of SWB, our data contains variables that can approximate the QoL and material conditions status of the individual surveyed. Concerning the material conditions, these three variables are included:-Income and wealth: Disposable income of the household (thousand Euros)-2Jobs and earnings: Unemployment -Housing: Real market value of the dwelling In turn, the next seven variables account for the QoL dimensions:-3Health status: Perception of own health -Work-life balance: Satisfaction with leisure time -4Education and skills: Education attainment -Social connections: Satisfaction with personal relations -Civic engagement and governance: Social trust -Environmental quality: Of the house and surroundings, including pollution and noise -5Personal security: Perception of delinquency in the zone We also include four socio-demographic variables:-Age: Expressed in years-Gender: 0-Man, 1-Woman-Cohabiting: 0-Single, 1-Married or cohabiting with a stable couple-Immigrant: 0-Immigrant, 1-SpanishIn summary, we have one measure of SWB, four socio-demographic variables, three indicators of material conditions and seven QoL variables. We established some filters for selecting the final sample for our study. First, we are only interested in the population between 18 and 65 years of age (working age). Second, we imposed the condition that all the variables contain a valid value for each individual. After applying these filters, the final sample size was reduced to 19,026 and 20,175 individuals for the years 2013 and 2018, respectively.As for the QoL variables, all of them improved during the period analyzed. Environmental quality, personal security and social connections obtain very large average scores in both periods. On the opposite side, education and skills and civic engagement and governance are the dimensions with lowest averages. These figures evidence weaknesses in the education system and distrust with the political and legal system. Fortunately, we see some steps in the right direction, since education raised from 5.87 to 6.40 during the period considered. It is also noteworthy the improvement in social connections, from 7.83 to 8.25.The evolution of SWB during the period under analysis is more interesting than the average values. The largest improvements are observed in Galicia (12.74%), Comunidad Valenciana (12.44%), Extremadura (12.25%), Islas Canarias (12.18%), Cantabria (12.02%), Baleares (11.27%), and Castilla y León (10.89%). On the other hand, we appreciate a slight regression in País Vasco (−2.24%) and Madrid (−1.68%). Interestingly, these last two ACs were the ones with lowest unemployment figures during the crisis. In contrast, the ACs that were hit hard by the crisis, with large unemployment rates, then registered a fast growth in activity and employment. Some of them are tightly associated with the recovery of the tourism sector .The empirical model relates SWB with a number of driving forces related to socio-demographic variables, material conditions of living and QoL variables. In both periods, age has a negative and significant effect. However, if we focus on the beta values, this variable was more influential in 2013. This result is consistent with the crisis scenario of 2013 as compared with the recovery picture of 2018. Even with material conditions controlled, the uncertainties introduced with the economic downturn had a special effect on the oldest individuals (within the working ages). SWB is not only affected by having an employment or not or having enough income or not. The positive or negative expectations about the evolution of these variables have a psychological impact, which hits specially the most vulnerable groups. Consistent with this, we also observe how the significant negative effect of being an immigrant  turns to be insignificant during the recovery period (2018).For 2013, our results show a significantly higher level of SWB for women than men, once the rest of the relevant variables on material conditions and QoL are controlled. In 2018, however, we find no significant difference across genders. Analyzing the evolution of SWB from a gender perspective is complicated, since contemporary societies are complex and have undergone profound transformations . The WHOThe last of the socio-demographic variables refers to cohabitation. As expected, living with a partner has a very positive and strong effect on self-perceived well-being (independently of being married or not). This favorable association between well-being and cohabitation may be especially relevant in times of economic downturn, as suggested by the Beta coefficients.Turning to the material conditions variables, all of them have a strong significant effect on SWB. The Beta coefficients point to unemployment as the variable with a greatest (negative) impact on SWB in both periods. We can also appreciate from the Beta coefficients that in 2013 this variable was far more critical than it was in 2018. This finding is again consistent with the expected effects of material conditions during crisis vs. recovery periods. Losing a job during a global downturn of the economy brings more uncertainty and psychological suffering than losing the same job in a recovery scenario. The effects on SWB do not come only from the fact of being unemployed, but on the subjective probability of finding a new job in the foreseeable future. Income and wealth would be the second variable in importance and then housing. These results are also in the line of past research, which document the strong negative effects of unemployment even after controlling for income and other material conditions variables.Finally, all the QoL variables, except environmental quality and personal safety, have positive and significant effects on SWB in both periods. The three variables with the highest explanatory power in both periods are social connections, health status and work-life balance.In short, our results point to social connections (a QoL variable) as the mayor single factor explaining SWB in both periods. Regarding the material conditions variables, unemployment is the main factor negatively affecting SWB, being the second factor in order of relative importance. This is a well-documented result in literature on SWB. However, we find that in 2018 (during the recovery phase of the economy), unemployment loses importance and drops to the fourth place . In other words, we find that during the recovery phase (2018), the three main explanatory factors are QoL variables, while in the crisis phase (2013), unemployment is the second driver with a very large beta coefficient.The models explain approximately 40% of the variance of SWB. This means there is still another 60% that cannot be explained by sociodemographic, material conditions and QoL variables. We should remember that SWB also has genetic components and is shaped by the personal experience of living. Therefore, it cannot be fully explained by measurable and objective variables. But there are some regularities that drive SWB in most cases in similar ways and relate to the variables examined in this paper. Our results indicate that people who live with someone, has sufficient income, a satisfying social life and good health will be much happier than people do not. Moreover, in times of crisis, unemployment has a much more devastating effect on our perception of well-being than in times of recovery.SWB is an individual perception of the own experience of living. As such, it reflects life circumstances, emotions and personality traits . It is aThe goal of this paper was not only to explore the driving factors behind SWB, but to analyze the time evolution of these relationships when the economic environment changes so dramatically. Some important results have emerged from this exercise of comparing crisis vs. recovery periods. The first has to do with the socio-demographic variables. Aging and cohabiting are very important driving factors of SWB. They have been consistently reported in past literature and they also emerge very clearly in this paper. As people grow older, the levels of SWB tend to go down, although the effect tends to reduce with aging itself. In addition, as expected, living with someone is one of the best recipes for a happy existence. In other words, loneliness is a sure route to unhappiness. These results are identical in both periods and, therefore, seem to be quite consistent.In contrast, the effects of gender on SWB are puzzling. Past literature has been inconclusive about the effect of being a woman or a man on the self-perception of well-being. In this study, we found that women scored significantly higher in 2013, both controlling and not-controlling for material conditions and other drivers of SWB. Interestingly, this effect has completely disappeared in 2018. One possible explanation behind this empirical finding may be related with a rise in female expectations during the last few years. The influence of the feminist movement toward equality may have (indirectly) increased the expectations of women with regards to their own lives, equating them in fact to those of men. This is a plausible hypothesis that should be analyzed in depth in future research with more data. It is also possible that women are increasingly comparing to other women and not to men, which may attenuate estimated gender differences in the subjective perception of well-being . In thisWith respect to the SWB gap of immigrants the results obtained are less puzzling and can be easily attributed to the evolution of the economy. As expected, in a crisis scenario, immigrants show significant lower levels of QoL. Actually, many immigrants returned their home countries during the economic crisis. When the economy recovered in 2018 this effect disappeared and the results show no significant differences between immigrants and Spanish nationals, regarding SWB .Our results also confirm the determinant relevance of unemployment in driving SWB. The effect of unemployment is larger than the effect of income, a result also largely documented in the literature. The interesting finding in our results is that the negative effect of unemployment is less determinant during the recovery phase of the economy. This is surprising, since the unemployed is equally unemployed regardless of the evolution of the whole economy. However, the finding is consistent with the well-known fact that the negative effect of unemployment on happiness comes from the fact of being unemployed rather than from the effect of the loss of income. If the effect is a psychological one, the expectations of the unemployed may play an important role. And the evolution of the economy will clearly affect those expectations. This is the psychological effect of being unemployed during a crisis period should be much harder than during a recovery phase. The unemployed that perceives the economy growing fast may hold positive expectations about the future. The prospect of finding a new job is more realistic than during an economic downturn.Finally, the models estimated also evidence the critical importance of QoL variables in driving SWB, especially when the economy is working well, and material conditions variables lose relevance. Social connections emerge as the single most important driver of SWB in both periods (doubling the beta coefficient of unemployment). Health status is the second driver in 2018 . This means that all the policies that may preserve the population in good health and with a stimulating social life will have an enormous impact on SWB.ceteris paribus the individual). It is our purpose to work on the elaboration of this panel of data.There are several limitations of our paper that we want to highlight, since they can open new opportunities for future research. First, even though our model explains a considerable portion of the variance in individual SWB, it also leaves much unexplained (around 50%). In other words, our results provide evidence that SWB is highly affected by the material conditions and QoL variables, but still a large part of it depends on personal subjective perceptions, feelings and psychological conditions. Future research should try to isolate the effect of the material conditions and QoL variables, by controlling the individual’s psychological traits. One way of doing this would be by collecting new data on the same sample of individuals, therefore creating a panel. Econometric estimation of panel data model, including individual effects, would be able to account for the unobserved heterogeneity arising from personal factors. Then, time variation in material conditions and QoL variables would determine the effects of material conditions and QoL variables on SWB , which are not necessarily the same as the ones included in this study. A deeper focus on a sample of older people would be necessary to assess these differences.https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736176807&menu=resultados&idp=1254735976608#!tabs-1254736194824.Publicly available datasets were analyzed in this study. This data can be found here: RA revised the literature, worked on the estimations, and prepared the figures in the manuscript. AC obtained the data required for the study, did the computations required in order to be ready for the estimations, and helped with the writing of the manuscript. EG coordinated the work, wrote the final version of the manuscript, and helped in estimating the regressions and discussing results. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Following the first proof of concept of using small nucleic acids to modulate gene expression, a long period of maturation led, at the end of the last century, to the first marketing authorization of an oligonucleotide-based therapy. Since then, 12 more compounds have hit the market and many more are in late clinical development. Many companies were founded to exploit their therapeutic potential and Big Pharma was quickly convinced that oligonucleotides could represent credible alternatives to protein-targeting products. Many technologies have been developed to improve oligonucleotide pharmacokinetics and pharmacodynamics. Initially targeting rare diseases and niche markets, oligonucleotides are now able to benefit large patient populations. However, there is still room for oligonucleotide improvement and further breakthroughs are likely to emerge in the coming years. In this review we provide an overview of therapeutic oligonucleotides. We present in particular the different types of oligonucleotides and their modes of action, the tissues they target and the routes by which they are administered to patients, and the therapeutic areas in which they are used. In addition, we present the different ways of patenting oligonucleotides. We finally discuss future challenges and opportunities for this drug-discovery platform. The development of new drugs requires two major steps: the identification of a therapeutically relevant target and the development of a compound capable of modulating its function. Over the past century, drug development efforts were focused on targeting proteins with different types of compounds including small molecules and monoclonal antibodies. Many drugs have thus been developed for the treatment of a large spectrum of pathologies and, to date, protein targeting remains a privileged avenue in drug discovery. However, the development of a compound capable of inhibiting or activating the function of a protein requires the recognition of its complicated spatial conformation. Although some classes of proteins such as membrane receptors, enzymes, ion channels, or transport proteins can be therapeutically approached using conventional protein-targeting strategies, other targets like transcription factors, scaffold proteins, or structural proteins are much less druggable using traditional modalities .An alternative to modulating the function of a protein is to modulate its expression level, and this can be achieved by acting on its mRNA (messenger ribonucleic acid). Oligonucleotides are a class of single- or double-stranded small synthetic nucleic acid polymers ≈20-mer) that can be used to modulate gene expression 0-mer tha. Since tThe use of oligonucleotides as therapeutic agents was first proposed in the late 1970s , but delAfter having experienced ups and downs, the field of therapeutic oligonucleotides is now rapidly growing. Since the first approval of an oligonucleotide for medical use in 1998 , 12 otheThe aim of this review is to provide an overview of therapeutic oligonucleotides on the market or in advanced clinical development. We present, in particular, the different types of oligonucleotides and their modes of action, the tissues they target, and the routes by which they are administered to patients, as well as the therapeutic areas in which they are used. In addition, we present the different ways of patenting oligonucleotides and how two of the world’s leading patent offices assess inventions relating to oligonucleotides.Clinicaltrials.gov (accessed on 20 November 2021), and PubMed for pertinent information on oligonucleotide drugs that target gene expression via direct interaction with RNA or DNA, with a focus on compounds that have hit the market or are in advanced stages of clinical development (phases II and III). We identified 93 compounds that meet these criteria. Among these oligonucleotides, 13 obtained approval between 1998 and 2021 and one is under regulatory review for approval (preregistration). One hundred and thirty phase II or phase III clinical trials involving 80 oligonucleotides are ongoing. These oligonucleotides are approved or tested in 102 different indications covering 14 therapeutic areas. They target 66 different genes.We searched GlobalData, The most represented oligonucleotides in our analysis are antisense oligonucleotides (ASOs) see a. They aGene expression-inhibiting ASOsAmong the gene-expression inhibitors, four have received marketing authorization, and 44 are currently in phase II or phase III clinical trials.The first ASO to be approved in 1998 was fomivirsen/Vitravene, an ASO drug targeting the cytomegalovirus (CMV) RNA sequence for the treatment of CMV retinitis in immunocompromised patients, including those with acquired immunodeficiency syndrome (AIDS) . HoweverFifteen years after this first access to the market by an oligonucleotide, a second ASO, mipomersen/Kynamro, was approved in 2013 for the treatment of homozygous familial hypercholesterolemia . MipomerTwo other modifications used in gapmer ASOs are currently in phase II clinical trials: (S)-constrained ethyl (cET) and locked nucleic acid (LNA)  11]. AZ. AZ11]. N-acetylgalactosamine  to an oligonucleotide  in order to direct a larger fraction of a dose to desired tissues and improve both cellular uptake and specific tissue targeting. Ionis Pharmaceuticals first used a technology developed by Alnylam consisting of conjugating Splicing–modifying ASOsThe second major group of ASOs consists of splicing modulators. To date, five splicing–modulating ASOs have received marketing authorization, and seven are in phase II or phase III clinical trials. All these compounds target rare genetic diseases.The best-known ASO in this group is nusinersen/Spinraza, which in December 2016 became the first approved drug used in the treatment of spinal muscular atrophy (SMA) . This raAnother CNS disease-targeting splicing modulator, STK-001, is currently being developed by Stoke Therapeutics for the treatment of Dravet syndrome, an autosomal dominant genetic disorder that causes a very severe form of epilepsy . STK-001Splicing modulation-based approaches have been the most widely explored for Duchenne muscular dystrophy (DMD), the most common form of inherited myopathies . To dateTwo exon-skipping ASOs developed by ProQR are being evaluated in clinical trials in genetic ophthalmologic diseases. Sepofarsen, an RNA antisense oligonucleotide that aims at restoring vision in Leber congenital amaurosis patients with the most common p.Cys998X mutation in the CEP290 gene, is currently in phase III . QRX-421The second type of oligonucleotides most represented in our analysis are siRNAs. They account for about 32% of the total number see a and fouSiRNAs are double-stranded RNA molecules capable of hybridizing specifically to their target RNA via Watson–Crick base pairings . Due to 3 group [The aforementioned siRNA drug patisiran, which was designed to inhibit the expression of the TTR gene, gained marketing approval for the treatment of familial amyloid neuropathies in 2018 . This si3 group . This mo3 group . PatisirIn 2019 a second siRNA developed by Alnylam, givosiran/Givlaari, was approved for the treatment of acute hepatic porphyria, a family of rare genetic diseases associated with hypomorphic mutations in genes encoding enzymes involved in heme synthesis . These mLumasiran was developed by Alnylam for the treatment of primary hyperoxaluria type 1 (PH1), a rare genetic disorder caused by mutations of the AGXT gene. The loss of function of the AGXT-encoded liver enzyme alanine:glyoxylate aminotransferase causes the liver to produce an excessive amount of oxalate, which accumulates in the kidney and induces kidney stones and kidney failure, leading ultimately to multi-organ damage. Lumasiran was designed to reduce hepatic levels of hydroxy acid oxidase 1 (HAO1), depleting glyoxylate, the substrate necessary for oxalate production, and thus preventing its pathogenic accumulation in PH1 patients.Inclisiran/Leqvio is a medication for the treatment of people with atherosclerotic cardiovascular disease (ASCVD) and hypercholesterolemia that was developed by The Medicines Company, which was acquired by Novartis in 2019. Inclisiran is a GalNAc conjugate that reduces the expression of liver proprotein convertase subtilisin/kexin type 9 (PCSK9). This protein plays a major regulatory role in cholesterol homeostasis, mainly by reducing LDLR levels on the plasma membrane, resulting in decreased metabolism of LDL particles, which can lead to hypercholesterolemia . PSCK9 hAmong the 30 siRNAs either on the market, in pre-registration, or in phase II or phase III clinical trials, 19 are GalNAc conjugates. Together with the 12 GalNAc-conjugated ASOs mentioned above, GalNAc conjugates represent a third of the total oligonucleotides identified in our analysis (31 out of 93) and almost 75% of the oligonucleotides with their target in the liver (31 out of 42). Any gene with pathogenic dysregulated expression in the liver can therefore be considered a potential target for oligonucleotide-based therapy. There are only two siRNAs unconjugated to GalNAc and targeting the liver: patisiran (previously mentioned) and BMS-986263, developed by Bristol-Myers Squibb and currently being evaluated in a phase II clinical trial for liver fibrosis . These tAmong the 93 oligonucleotides in our analysis, only three are not ASOs or siRNAs: remlarsen and lademirsen, which act through mechanisms involving miRNAs and MTL-CEBPA, a small activating RNA (saRNA) .MicroRNAs are small noncoding RNAs that function as important posttranscriptional regulators of gene expression . They caAll the oligonucleotides mentioned above target transcripts  to regulate gene expression by acting post-transcriptionally on RNA degradation, splicing, or translation regulation. Small activating RNA (saRNA) is a distinct class of non-coding RNAs that act in a completely different way since they target selected sequences in gene promoters to induce gene activation at the transcriptional/epigenetic level by a process known as RNA activation (RNAa) . SaRNAs In the next sections we provide information on oligonucleotide target genes, target tissues, the routes by which they are administered to patients, and the therapeutic areas in which they are used.Although membrane receptors and enzymes are classically the targets of small molecules, and extracellular proteins or membrane receptors can be modulated with monoclonal antibodies, certain types of proteins such as structural proteins or transcription factors are generally hardly “druggable” . Since thttps://www.atlantichc.com/research/alicaforsen/, accessed on 5 January 2022).We analyzed the oligonucleotides according to the tissues they target and their route of administration. Data are presented in The CNS is one of the most represented tissues in our analysis and is targeted by 14% of oligonucleotides. Due to the blood–brain barrier (BBB), the CNS cannot be reached after systemic administration such as subcutaneous or intravenous injections. Therefore, oligonucleotides targeting the CNS are all injected intrathecally into the CSF via lumbar puncture. The vast majority of CNS-targeting oligonucleotides (10 out of 14) contain PS and 2′-MOE modifications and exhibit unusual pharmacokinetic and pharmacodynamic properties, including complex active absorption mechanisms, low systemic exposure, extremely long half-lives, and accumulation and gradual release from subcellular deposits . These pLike the CNS, the eye was one of the most represented organs in our analysis since it is targeted by 11% of oligonucleotides. Due to the blood–ocular barrier (BOB) that prevents drugs from traveling between the local blood vessels and most parts of the eye itself, eye targeting requires topical administration. This is a real advantage since the oligonucleotides administered in the eye do not pass into the bloodstream and only exert their effect locally, which reduces the side effects. Different routes of administration are used depending on the tissue to be reached: The ocular route via eye drop is mainly used to target the cornea, whereas targeting the retina requires more invasive intravitreal injections.Other types of topical administrations can be used: Intradermal injections are used for skin targeting, whereas oligonucleotides can be inhaled for respiratory tract targeting.Given the wide variety of tissues that can be targeted, oligonucleotide-based therapies can potentially be applied to all therapeutic areas and for many indications. The 93 oligonucleotides identified in our analysis are approved or tested in 102 different indications covering 14 therapeutic areas. With the exception of fomivirsen/Vitravene, which treated CMV retinitis, the first oligonucleotides were developed to treat genetic diseases. Of the 13 oligonucleotides that hit the market, 11 target rare genetic diseases. In many cases, the target gene of the oligonucleotide corresponds to the gene mutated in the disease. In 2020, inclisiran was the very first oligonucleotide drug benefiting a large population of patients with non-genetic disorders to be approved for medical use in metabolic and cardiovascular disorders. An increasing number of oligonucleotides is being developed for non-genetic diseases. To date, of the 102 indications found in our analysis, almost 75% are non-genetic diseases.The distribution of the oligonucleotides according to the therapeutic areas is presented in The second most represented therapeutic area is oncology (18%). Given that oncology is by far the therapeutic area most targeted by compounds developed by the pharmaceutical industry, the proportion of oligonucleotides in oncology remains relatively low. Only one phase III and eight phase II compounds are currently being evaluated in clinical trials and none has yet reached the market. In this therapeutic area, other modalities such as small molecules and monoclonal antibodies are still largely privileged.Consistent with the pharmacokinetic and pharmacodynamic properties of oligonucleotides in the CSF described in the previous section, neurology is one of the main therapeutic areas for oligonucleotide therapeutics .Thanks to the specific targeting of the eye due to the modes of administration, ophthalmology is also a therapeutic area of choice for oligonucleotides (9%). Although no oligonucleotide has yet received marketing authorization in this therapeutic area, five phase III clinical trials involving oligonucleotides are ongoing in ophthalmology .Muscular disorders are targeted by 7% of total oligonucleotides and four out of 13 approved oligonucleotides. This is due to the very active research on Duchenne muscular dystrophy and in particular on the development of exon-skipping strategies to restore dystrophin function. Among the nine oligonucleotides developed for muscular diseases, only DYN-101, developed by Dynacure, targets another muscular pathology. DYN101 is designed to reduce the expression of dynamin 2 protein in several pathologies and is currently being evaluated in a phase II clinical trial for the treatment of X-linked myotubular myopathy .Infectious diseases are also targeted by therapeutic oligonucleotides, in particular in the field of virology. As mentioned earlier, the first oligonucleotide to enter the market targeted CMV viral sequences for the treatment of CMV retinitis in immunocompromised patients . SeveralOther therapeutic areas, including dermatology, hematology, respiratory, endocrinology, and immunology, are also targeted by oligonucleotide therapeutics.www.wipo.int, accessed on 20 November 2021), more than 89,000 references are identified with the code C12N 15/113, which corresponds to “Non-coding nucleic acids modulating gene expression, e.g., antisense oligonucleotides”.As discussed, great development of oligonucleotide therapeutics has been in progress for several decades by many actors and, to date, 44 companies have molecules on the market or in advanced clinical development see . The twoThe goal of a company trying to protect an innovation is to obtain the strongest and broadest scope of protection. However, depending on different aspects  the drafting of the patent claims can differ, and the different patent offices may evaluate the invention differently. The purpose of this section is to provide an overview of the different types of protection that can be obtained and how the patent offices assess them.Oligonucleotide therapeutics are generally used to (i) induce the degradation of an mRNA or non-coding RNA, (ii) inhibit the translation of an mRNA, (iii) induce splice switching, or (iv) activate the transcription of a gene (saRNA). For these purposes, inventors must design at least one oligonucleotide  that will target a specific gene.Thus, to obtain protection for a given oligonucleotide, the invention must be disclosed in a sufficiently clear and concise manner (=disclosure of the invention) and must also be new, involve an inventive step, and be capable of industrial application. An invention is new if it does not form part of the state of the art and involves an inventive step if, with regard to the state of the art, the solution given by the invention is not obvious to a person skilled in the art. If these two first criteria are analyzed in view of the state of art, the industrial application criterion is often easy to fulfill, because it is only necessary that the invention be made or used in any kind of industry, including agriculture.Like many products, there are different strategies to protect oligonucleotides. For example, it is possible to protect the nucleic acid sequence of the oligonucleotide itself, a method of treatment based on the targeting of a gene or a region of an mRNA by an oligonucleotide or a new “format” (or scaffold) of an oligonucleotide. However, the patentability of this type of invention is judged differently according to the inventions and according to the patent offices.The aim of the next part is to take stock of the practice in the field of oligonucleotide therapeutics and to explain the different strategies of protection and how the EP and US patent offices evaluate this kind of invention. The analysis of the novelty and inventive step criteria will not be discussed in detail here, but Oligonucleotides can be defined by a functional definition or by a structural definition. Indeed, when broad protection is requested and when the target of the oligonucleotide (the gene to be targeted) and its involvement in a pathology is new, a functional definition of the invention is possible. The writer will be able to define the oligonucleotide by its capacity to target the specific gene. Here is a theoretical example of a functional definition of a claim  to protect the product as such and to provide fallback positions if the claim with the functional definition is not accepted.If the target is not new, it is not possible to claim all oligonucleotides targeting the gene, but it is still possible to try to claim all oligonucleotides targeting a region of the mRNA. To this end, it is important to demonstrate that targeting the specific region of the mRNA confers a better effect than targeting other regions of the mRNA. Here is a theoretical example of a functional definition of a claim  and thus write a structural definition of the oligonucleotides. The writing of this protection is quite common and easy to implement. The oligonucleotides for which protection is required are defined by their nucleic acid sequences, and these sequences are described in the patent application and in a sequence listing. ID numbers are attributed to each sequence (ex.: SEQ ID NO: X). Here is a theoretical example of a structural definition of a claim N-aattccgwherein (x) is any nucleic acid and N is comprised between 1 and 10,wherein the nucleic acids of the oligonucleotide are linked by covalent bonds, andwherein the oligonucleotide has no more than 60% guanosine nucleobases.”Finally, another specificity concerning the protection of oligonucleotides is that modifications/improvements can also contribute to protecting a new object. Indeed, the inventors always seek to improve the efficiency of oligonucleotides—for example, in terms of their stability, their ability to enter in the cells, their half-life, etc. Thus, the modifications of the oligonucleotides, such as the addition of specific chemical group like GalNAc (see above) developed by Alnylam, can be protected itself but can also be used to improve the protection of the oligonucleotide already filed in a patent application , oligonucleotides are eligible, and it is usually not a problem to get a patent with a structural definition, if the patentability criteria are recognized , it is necessary to provide experimental data describing different oligonucleotides with the modification.Of course, in all these cases, the novelty and the inventive step are particularly studied by the EPO in regards to the prior art see .Another particularity with the EPO is that methods of treatment are not accepted because they are not patentable under article 53(c) of the European Patent Convention (EPC). However, the use of specific oligonucleotides for the treatment of a disease are accepted . Thus, a broad scope including, for example, all oligonucleotides targeting a gene or mRNA region for use in the treatment of a disease are also accepted if several examples are described in the patent application (see above) and, of course, if the novelty and the inventive step criteria are met.www.uspto.gov, accessed on 20 November 2021), the situation is quite different. Indeed, obtaining functional definition or structural definition claims can be much more difficult.In the United States, at the USPTO  use this route of administration. Compared to the intravenous route, subcutaneous injection offers the advantage of potentially being self-administered, eliminating the need for patients to repeatedly visit a medical facility. Further improvements in terms of patient convenience could result from the development of formulations compatible with oral administration. Important developments are underway to allow oligonucleotide administration by this route, which is the one most used for drugs and the easiest for patients to use. A recent study led by AstraZeneca showed that an ASO conjugated to GalNAc and co-formulated in a tablet with sodium caprate can be delivered orally and absorbed by the liver, where it reduces the expression of its target gene (PCSK9) . Sodium To date, most oligonucleotides developed as drugs are gene-expression inhibitors . Expression-inhibiting oligonucleotides have proven to be efficient therapeutic agents when a target requires inhibition, and eight compounds including ASOs and siRNAs have reached the market ,45,46,47Lastly, we highlighted in this review that patenting oligonucleotides is of great importance for the companies exploiting this technology and that the examination of the patentability of the invention can differ from one country to another. Our recommendation as a tech transfer office is to provide for all aspects the broadest protection possible , because depending on the territory , the protection may not be the same in the end.In conclusion, oligonucleotides have demonstrated their ability to produce major therapeutic benefits for patients and further developments will likely lead to even better drugs coming to the market in the near future.


With the growing number of open access (OA) mandates, the accurate measurement of OA publishing is an important policy issue. Existing studies have provided estimates of the prevalence of OA publications ranging from 27.9% to 53.7%, depending on the data source and period of investigation. This paper aims at providing a comparison of the proportion of OA publishing as represented in two major bibliometric databases, Web of Science (WoS) and Dimensions, and assesses how the choice of database affects the measurement of OA across different countries. Results show that a higher proportion of publications indexed in Dimensions are OA than those indexed by WoS, and that this is particularly true for publications originating from outside North America and Europe. The paper concludes with a discussion of the cause and consequences of these differences, motivating the use of more inclusive databases when examining OA, especially for publications originating beyond North America and Europe. Over the past 30 years, the democratization of the internet has made it possible for researchers, journals, and publishers to provide free online access to scholarly papers. This practice, also known as open access (OA), allows anyone with an internet connection to access, read, distribute, and download scientific publications for free with no legal or technical barriers . OA publThe advantages of OA have been well-documented: increased global visibility , higher The Science Citation Index (SCI) was originally developed by Eugene Garfield  to help For instance, Mongeon and Paul-Hus  have shoCountries differ in the proportion of their publications that are OA , 9, 21. http://roar.eprints.org/). Conversely, authors from developing countries tend to make use of OA journals [The approach used by developing and developed countries for OA dissemination have historically been different , 10. Devjournals  with varIn addition, OA is built on the assumption that internet access is a basic public utility that is reliably and conveniently available to everyone. This flawed assumption places developing countries at a significant disadvantage when discussing, implementing infrastructures to support, and benefitting from OA . For exaWe investigated all journal-based publications indexed in WoS and Dimensions for publication years 2015 to 2019 for which first author country affiliation data was available. Both data for Dimensions and WoS were obtained from the data providers and transformed into SQL databases for data compilation. OA status for WoS papers was obtained by linking the database with Unpaywall . For DiGold: Published in an OA journal that is indexed by the Directory of Open Access Journals (DOAJ).Green only: Toll-access on the publisher page but is free in an OA repository.Hybrid: Free under an OA license in a toll-access journal.Bronze: Free to read on the publisher page, but without a clearly identifiable license.Closed: All other publications, including those shared only on an Academic Social Network (ASN) or in Sci-Hub.While papers can be self-archived (green OA) and published as OA through a journal , in this study we assigned only one OA category to a paper, giving priority to journal-based OA status. Each publication was assigned to a single country based on the country affiliation that appeared on the publications for the first author. We then used the World Bank Country Classification to assign each publication into a region . The difOf WoS and Dimensions publications with affiliation data, 43.4% of WoS publications and 46.6% of the Dimensions publications are available as OA publications, as shown in Strong differences can be seen when examining according to regions . For devThese proportions differ substantially when considering different types of OA . For allx representing the percentage of papers for the country in the Dimensions dataset that are OA, and y representing the percentage of papers for the country in the WoS dataset that are OA, was used to calculate the relative difference between the percentages. This results in a measure where a value of -1 indicates countries for which Dimensions indexes no OA publications, whereas a value of 1 indicates those countries for which WoS indexes no OA publications, i.e., the closer to 0 the more similar the databases are in their percentage of OA publications indexed for the country in question. In Basson et al.  found thOur results show that the measurement of OA differs when using WoS or Dimensions, and that the difference is more striking for authors from outside North America, Europe, and Central Asia. Given the Western bias of journals indexed in WoS —which arThis has implications for the distribution of different types of OA, as the literature suggests that the countries generally represented in WoS are also those that tend to more often make use of self-archiving (green OA). This is observed when investigating green only OA, the only OA type that is consistently higher in WoS than in Dimensions, and substantially higher for North America, Europe, and Central Asia. The focus on self-archiving in these regions potentially explains the larger percentage of green only OA publications in WoS, as various mandates are applicable, and many repositories are available, to these authors. The higher percentage of bronze OA in Dimensions for all regions could reflect the inclusion of many non-DOAJ listed journal publications in Dimensions. It is likely that these bronze OA publications are in journals not published by the major publishers and lack the same level of standardization in metadata, resulting in difficulty classifying the publications and their inability to be indexed in DOAJ. It is also possible that due to the broad inclusion criteria of Dimensions that some predatory journals are included in this bronze OA category  or that these bronze publications are of document types not included in the WoS dataset used for this study . Further research is required to investigate the characteristics of the additional publications included in Dimensions.Lastly, this difference in measurement is most clearly illustrated at the level of countries. If WoS is used to measure OA for countries, the OA percentage tends to be lower for some countries in comparison to a more inclusive database such as Dimensions. Just as OA aims to provide visibility and access to research publications beyond toll-access journals, Dimensions provides a lens to investigate a broader number of publications, as opposed to only those that are considered to be the most relevant or core by Western-centric data sources such as WoS or Scopus. However, this larger coverage is not without challenges. Despite indexing more papers than WoS, Dimensions has a larger percentage of articles with missing metadata. This is particularly an issue for affiliations , 42, whiAlong those lines, the lack of disaggregation of document types within Dimensions for journal publications not only hinders the ability to examine the characteristics of Dimensions, but also limits the possibility to conduct bibliometric studies, especially comparative ones. Considering the philosophy behind Dimensions of “combining a comprehensive coverage of the scientific literature with a flexible set of filters for making selections of the literature” , one hopDespite these challenges, our analysis shows that the measurement of OA may differ significantly when one looks beyond the subset of most cited journals. Ultimately, given that Dimensions indexes journals published by the many platforms developed in the South—AJOL (Africa), AmeliCA (Latin America), and SciELO (Brazil)—it has the potential to be a more suitable platform for a more inclusive measurement of OA uptake, especially of publications by authors from outside North America, Europe, and Central Asia.


Neonatal cholestasis (NC) may be due to multiple surgical and non-surgical causes, some of which are potentially fatal. The list of potential causes of NC is long, and the systematic search for each of them is challenging in infants, especially when overt signs of underlying disease are lacking. Endocrinological diseases as causes of NC are rare and sometimes misdiagnosed. We report the case of an infant with prolonged cholestatic jaundice due to adrenal insufficiency suspected because of a single episode of hypoglycemia occurring at birth in the absence of clinical signs of adrenal impairment. Clinical exome analysis identified a new homozygous variant in MC2R gene as a putative responsible for familial glucocorticoid deficiency (FGD). Adrenal insufficiency should always be considered in all cholestatic infants, even in the absence of specific symptoms, since early recognition and treatment is essential to prevent life-threatening events. Neonatal cholestasis (NC) is defined as an impairment in bile flow resulting in retention of bile substances, generally characterized by an increase in serum direct bilirubin and bile acid levels . It may 2 supplementation for the first 48 h of life. During hospitalization, the neonate underwent transfontanellar and abdominal ultrasounds with normal results. Echocardiography showed muscular ventricular septal defect with mild left-to-right shunt without hemodynamic consequences. Complete blood count, coagulation, blood culture, and urinalysis were normal. Extended neonatal screening for metabolic diseases, performed according to regional guidelines  with very high levels of ACTH  suggestive of PAI . Adrenal2/day) with early normalization of conjugated bilirubin values. Ursodeoxycholic acid therapy was withdrawn at the age of 2 months with no recurrence of cholestasis. During the follow-up, a trend toward progressive increase in renin levels  was observed, and mineralocorticoid replacement therapy was introduced at 55 days of life.The child was promptly treated with hydrocortisone , was performed in trio  to identify the etiology of PAI. The analysis showed that in the proband, a previously unreported Thr33Lys homozygous variant in MC2R gene was potentially responsible for FGD. The Sanger sequencing confirmed the same variant in both the parents in a heterozygous state.On the last observation, the patient was 9 months old, of general well-being, on stable therapy with hydrocortisone and fludrocortisone. His weight and length were appropriate for his age, and the serum bilirubin and electrolytes values were normal. In the neonatal period, the liver responds with cholestasis to numerous stimuli for which an impairment in bile flow can result from multiple entities including endocrinological disorders, which are rare and sometimes misdiagnosed , 9. It iPAI is a potentially life-threatening disorder requiring prompt recognition and treatment , 14. SinPresentation of AI with cholestasis is limited only to the early infantile period, but in the cases reported so far, cholestasis was associated with extrahepatic manifestations. Beyond infancy, the hepatic manifestations due to AI include elevation of liver enzymes but not cholestasis . InfantsChildren with FGD usually respond very well to glucocorticoid replacement even if serum ACTH levels can remain high . In the Partial or complete deficiency of sex hormones such as testosterone, progesterone, and dehydroepiandrosterone sulfate was reported in several FGD patients , 20. AltThe main message of this case report is to encourage pediatricians to systematically research PAI in all cases of NC including paucisymptomatic patients and also in the absence of overt signs of AI. In fact, in our case, hypoglycemia was only transient, while the unexplained cholestasis was the main sign presented. It is to note that even after 6 h of fasting required for abdominal ultrasound, no hypoglycemia occurred in our patient. This could lead to the neglect of the single episode of hypoglycemia at birth. It is to note that while hypoglycemia associated with perinatal risk factors such as low gestational age and low birth weight may reasonably not be considered a warning sign, in the absence of risk factors (as in our case), hypoglycemia has to be valued.The systematic search for endocrinological causes in all cholestatic infants raises the question on how far it is necessary to extend the search for possible etiologies in paucisymptomatic cholestatic infants. These considerations are also of value for the economic implications and the awareness that the NC can be transient in a variable number of cases , 22. As In conclusion, this case of FGD, associated with a novel variant in MC2R gene, presenting only with NC and a single transient episode of hypoglycemia, should alert physicians to investigate the presence of PAI in order to favor prompt recognition and treatment replacement and avoid further invasive diagnostic tests including liver biopsy in any infant with unexplained cholestasis.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.FDD and RI: article conception. RM and FDVB: data collection. FDD, FDVB, MS, and DC: data analysis and interpretation. FDD and RM: drafting of the manuscript. RI, MS, and DC: critical revision of the manuscript. All authors approved the final version of the manuscript and agree to be accountable for the content of the work.Department of Translational Medical Science of University of Naples Federico II provides funds for open access publication fee.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Clinical trials are a critical step in the meaningful translation of biomedical discoveries into effective diagnostic and therapeutic interventions. Quality by design (QbD) is a framework for embedding quality into the design, conduct, and monitoring of clinical trials. Here we report the feasibility and acceptability of a process for implementing QbD in clinical research at an academic health center via multidisciplinary design studios aimed at identifying and prioritizing critical to quality (CTQ) factors.The Clinical Trial Transformation Initiative’s Principles Document served as a guide to identify and categorize key CTQ factors, defined as elements of a clinical trial that are critical to patient safety and data integrity. Individual trials were reviewed in CTQ design studios (CTQ-DS) and the feasibility and acceptability of this intervention was examined through post-meeting interviews and surveys.Eight clinical research protocols underwent the QbD evaluation process. The protocols ranged from multicenter randomized clinical trials to nonrandomized investigator-initiated studies. A developmental evaluation informed the iterative refinement of the CTQ-DS process, and post-meeting surveys revealed that CTQ-DS were highly valued by principal investigators (PIs) and resulted in multiple protocol changes.The present study demonstrated that QbD principles can be implemented to inform the design and conduct of clinical research at an academic health center using multidisciplinary design studios aimed at identifying and prioritizing CTQ elements. This approach was well received by the participants including study PIs. Future research will need to evaluate the effectiveness of this approach in improving the quality of clinical research. The fundamental goal of translational research is to bridge the divide between preclinical discoveries and clinically relevant therapies and interventions. Meaningful translation can only occur with clinical trials that address salient health challenges, efficiently generate accurate evidence, minimize participant risk, assure inclusion of underrepresented populations, and engage all stakeholders at early phases of protocol development ,2. HowevOver the past few decades, there have been various efforts aimed at creating and disseminating innovative approaches that help embed quality metrics into the design, conduct, and monitoring of clinical trials. These efforts have been led by key stakeholders in the global clinical trial enterprise, including international regulatory agencies , the pharmaceutical and medical device industries, National Institute of Health (NIH), and academic institutions –12. One The key principles underlying QbD emanate from the endeavors of pioneering scientists in the mid-1900s  who creThe task of adapting QbD principles to clinical research was initiated by the Clinical Trial Transformation Initiative as part of a multistakeholder project. Significant progress has been made thus far in defining the applicable principles and components of QbD that may be relevant to clinical trials. In this regard, the QbD approach has focused on identifying what is CTQ in a particular study with subsequent tailoring of the protocol design to eliminate unnecessary complexity, avoid predictable errors, as well as devise a focused, efficient, and streamlined monitoring and auditing plan for oversight . CTQ in To help stakeholders in clinical research better understand and apply these concepts, Clinical Trial Transformation Initiative has developed a set of CTQ factors, as documented in the CTQ Factors Principles Document, where application of QbD, and specifically systematic, high-quality study planning, has been conceptually described . The CTQAs the first step in this process, key stakeholders involved in clinical research at UC Irvine were made aware of QbD concepts including CTQ factors. This was accomplished through a one-day workshop sponsored by our CTSA hub  and Clinical Trial Transformation Initiative. The attendees included organizational leaders in the School of Medicine, as well as key personnel involved in clinical research development and administration at our institution. The workshop not only provided a didactic session describing QbD concepts and key components of the CTQ Principles Document but it also involved case studies of previous and prospective trials at UC Irvine in a participatory demonstration of the QbD approach.This informative session was conducive to educating the UC Irvine clinical research community about the QbD approach and providing practical examples on how this methodology can be used to improve the design and overall quality of clinical research at our institution. Post-workshop surveys confirmed that the majority of attendees favored adoption of QbD concepts in their own research as well as at the institutional level Table . We alsoA smaller planning group subsequently outlined a strategy to construct a core working group with expertise in principles of QbD and various aspects of clinical trial design and invite PIs in the planning stages of clinical research to submit their draft protocol to the working group for feedback. In addition to the core working group, each CTQ-DS would include a member representing the patient perspective as well as content experts specific to the study topic. Rather than being a regulatory hurdle, the CTQ-DS would serve as a resource to investigators and help them design and establish a monitoring plan tailored for their study.The QbD working group was created with the goal of conducting CTQ-DS for individual clinical trials at the earliest stages of study development. The working group was made up of core members who were selected based on their expertise in areas of critical importance shared by all clinical trials Table , includiTo incorporate the patient perspective into the design and conduct of the study, the ad hoc group also included a patient/participant representative who was selected based on the condition being studied. Awardees of training grants (such as K and T awardees) were also invited to CTQ-DSs where they had a chance to learn and apply QbD concepts in order to further disseminate the QbD approach . Core anTo enable reproducibility and facilitate implementation, the design studios were planned and conducted using a set structure which was regularly assessed and updated Fig. . The pro1) one week prior to the meeting in order for the participants to identify a list of preliminary CTQs which were collated in advance of the meeting. On the day of the CTQ-DS, the meeting began with a brief (10-minute) presentation on the main aspects of the trial design by the PI. The session was then opened to discussion including questions and feedback aimed at further clarifying key design, conduct, and monitoring elements of the study. At this time, CTQ elements were identified and shared with the PI. The meeting was conducted as such to ensure feedback was received from all participants of the design studio, especially the patient/participant advocate.Once the PI agreed to partake in this process, a CTQ-DS meeting was scheduled based on the availability of all the members including the patient/participant advocate. The PI provided a 3–4-page description of study rationale, design, and implementation plan . Once a prioritized list of CTQs was compiled, a design studio report was generated using a set template that has been developed over the course of this project. The report began by providing a brief background on QbD concepts and the purpose of the CTQ-DS. Subsequently, descriptions regarding the meaning of the report, its findings, and helpful references were provided. Finally, tables listing CTQs along with their priority scores, beginning with a table of top 10–15 CTQs (those with priority scores in the one range) followed by tables of other CTQs organized based on their CTQ category, were provided in the report. The report was then emailed to the PI and research team. The details involved in selection of a study, planning, and conducting CTQ-DS were used to create a standard operating procedure (SOP) . Surveys of the participants and PIs were used to improve the procedures and modify the SOP as well as the CTQ prioritization scheme.In addition to sessions being recorded, a notetaker documented all elements of the discussion at the time of the meeting. Post-meeting, a list of CTQ factors was compiled based on the notes and recording from the session, and according to the different categories of CTQs codified in the Principle’s Document. Final prioritization of the CTQs was accomplished using a REDCap survey where the CTQ-DS attendees were asked to rate the priority score of each CTQ . REDCap Using a developmental approach to evaluation , the forPerceived impact of the CTQ-DS from the perspective of all participating PIs was assessed with a REDCap survey administered in April of 2021. Thus, the time elapsed between the CTQ-DS and the follow-up PI survey ranged from a minimum of 2 months to a maximum of 20 months. On the follow-up survey, PIs were asked to report on the status of their study, their perceptions of the utility of the CTQ-DS, and what action, if any, they had taken with respect to each of the CTQs identified in the report that they were provided following the CTQ-DS.Over the past 2 years, our team has reviewed eight separate clinical research protocols via the CTQ-DS at UC Irvine, including five during the COVID-19 pandemic. While the initial three meetings were conducted in-person and via roundtable discussions, due to the social distancing restrictions put in place during the pandemic, the remaining five meetings were conducted using virtual technologies. We found that conducting virtual meetings did not decrease participation or enthusiasm for holding CTQ-DS. In fact, by using virtual technologies, we were able to reduce the barriers posed by commute time and geography. The studies that underwent the QbD process via CTQ-DS included a wide range of clinical research designs Table . Half , suggesting that the stem cell trial was an outlier. The post-meeting data collection (Supplement Table 4) led to improvements in the way that pre-meeting materials were formatted and delivered to the working group as well as how the meeting itself was structured. Similarly, feedback on the prioritization scoring method led to implementation of a simplified version for the last four studios, with indications that this approach was highly acceptable to working group members.Supplement Table All eight PIs who participated in the CTQ-DS responded to an online survey asking about their experience Table . ResponsThe principles of QbD have been developed and adopted in various industries, including in pharmaceutical manufacturing. More recently, their potential application in clinical research has been described through multistakeholder efforts, which have included regulators, members of academia, as well as the pharmaceutical and medical device industry. While there are many resources available that describe QbD concepts as they relate to biomedical research, specific examples for adoption and implementation of this approach have remained lacking. In this manuscript, we have described a formal pathway for implementation of QbD at an academic health center using identification and prioritization of CTQ factors, which are key components of this approach. We achieved this through establishment of a formal CTQ-DS with the goal of embedding QbD principles into the design and management plan of clinical research protocols proposed at our institution. During the past 2 years, we conducted eight CTQ-DS, each reviewing a unique clinical research study. The majority of the meetings were held virtually due to COVID-19 pandemic restrictions.We continuously improved the planning, conduct, and reporting process for our design studios and based on the latter knowledge, we devised a standard operating procedure that can be adapted for settings outside of our institution. Finally, we conducted a survey to evaluate the participating PIs’ perception of value and the utility of CTQ-DS in improving the design and conduct of their study. The results show that CTQ-DS were well received and have played a valuable role in helping PIs proactively anticipate aspects of the trial protocol that were deemed to be important and adjust their protocol accordingly to address these findings. The only study that did not report protocol changes in response to the CTQ-DS was a multisite clinical trial. This finding is not surprising given the many difficulties involved in changing the design of studies that have already been finalized, especially multicenter studies, which have already gone through many iterations and are less amenable to change. Therefore, our findings indicate that CTQ-DS are most useful for clinical studies at the design stage. However, it is possible that even for a finalized protocol the findings from a CTQ-DS could still be helpful in creating a site-specific trial management plan and improving the feasibility of the study at a single implementing institution, although this remains to be determined in future follow-up evaluations.There are several important aspects of our efforts that merit highlighting. In recent years, there has been increasing recognition of the critical need for a team-science approach to the development and conduct of translational research –30. ThisThe role played by participant advocates in the design of clinical trials is also critical. Novel approaches, such as the use of community engagement studios , are incThe implementation of QbD via CTQ-DS not only was well received by our PIs as a resource to help them better design and develop their studies but it also provided an opportunity for our researchers to incorporate the latest recommendations of the upcoming ICH E8 and ICH E6 renovations into their clinical research protocols ,34. ThesSome of the limitations of our approach also need to be mentioned. Our system for applying QbD concepts is especially suited for academic institutions and adoption of a similar scheme in smaller organizations may be challenging. At academic health centers, we have access to a wide pool of experts to populate our working group. Moreover, these individuals were willing to participate as an element of their University Service and did not require compensation. This approach may not be feasible in smaller organizations or those with differing priorities. However, we believe that the concepts highlighted in our study  can be adapted and tailored for other settings, including commercial settings. For instance, partnerships can be formed between multiple organizations with the goal of creating CTQ-DS that can help review a variety of external and internal studies, much like central and commercial institutional review boards. Another important limitation of the QbD approach is that it remains to be demonstrated that adoption of QbD or any other mechanism for incorporating quality metrics into clinical research will in fact improve quality of clinical studies. Therefore, it is important that future, carefully designed and controlled studies address this critical question . In addition, relevant qualitative and quantitative endpoints need to be identified and validated in order to help with evaluation of QbD efficacy in improving quality of clinical research. In fact, we are planning studies to address these important gaps in order to plan future larger studies examining QbD effectiveness. Nevertheless, a formalized approach for implementation of QbD at academic health centers, which can then be adopted at other institutions, will be the critical first step to enable future research to test the comparative effectiveness of QbD (as opposed to current common practices) in improving quality in clinical research. Hence, our approach for operationalizing QbD can serve as a platform for adoption of QbD at other academic health centers and thereby facilitate future multicenter effectiveness evaluation of the QbD approach. Finally, there are pitfalls that we encountered during the implementation of our approach that other investigators need to be aware of and account for in their planning. First, CTQ-DS require participation of many faculty, staff, and other participants and this requires time commitment and coordination of schedules for a sizeable number of individuals. Sessions need to be planned and scheduled 1–2 months in advance in order to facilitate this process. Second, identification of clinical studies and PIs who are eligible and willing to participate in design studios requires planning and support from organizational areas involved in clinical research . We found that this process needs to be planned several months in advance in order to help successful identification of a project and to assist PIs with some of the requirements of this process . Preplanning is also critical to include patient representatives in the design studios. Most of our patient representatives were identified and invited by the PI of the under review, but in cases where these PIs lacked such contacts, it was useful to reach out to the Community Engagement Unit of our Clinical and Translational Science Award hub for assistance. Lastly, ongoing surveys and feedback from participants have been used to optimize many of the operational aspects of the design studios. These included the CTQ identification a scheme and the scoring system used to prioritize CTQs. Therefore, continuous evaluation and improvement of the CTQ-DS processes are crucial to the successful implementation of this approach in a changing academic environment.In conclusion, we have demonstrated that adoption of QbD concepts is feasible through administration of multidisciplinary design studios focused on CTQ factors specific to each study. Moreover, the studios were perceived as extremely valuable by the participating PIs and stimulated PIs to address the identified factors in their protocol revisions. Future studies will need to determine whether implementation of QbD using this approach improves quality of clinical research at academic health centers.


Background: There has been a rapid increase in morbidity and mortality arising from non-communicable diseases (NCDs). The Academic Model Providing Access to Healthcare (AMPATH) program has established a chronic disease management program in collaboration with the Ministry of Health (MoH) in Kenya at over 150 health facilities in western Kenya. The primary health integrated care for chronic (PIC4C) disease project seeks to deliver preventive, promotive, and curative care for diabetes, hypertension, cervical and breast cancers at the primary health care level. We apply the RE-AIM framework to conduct a process evaluation of the integrated PIC4C model. This paper describes the protocol we are using in the PIC4C process evaluation planning and activities.Methods and Analysis: This evaluation utilizes clinic reports as well as primary data collected in two waves. Using mixed methods , the process evaluation assesses the reach, effectiveness, adoption, implementation and maintenance of the PIC4C model in Busia and Trans Nzoia Kenya. The evaluation captures the PIC4C process, experiences of implementers and users, and the wishes of those using the PIC4C services. We will analyse our data across the RE-AIM dimensions using descriptive statistics and two-sample t-test to compare the mean scores for baseline and end line. Qualitative data will be analyzed thematically.Discussion: The process evaluation of the PIC4C model in Kenya allows implementers and users to reflect and question its implementation, uptake and maintenance. Our experiences thus far suggest practicable strategies to facilitate primary health care can benefit extensively from deliberate process evaluation of the programs undertaken. Furthermore, integrating the RE-AIM framework in the process evaluation of health programs is valuable due to its pragmatic and reporting usefulness. Sub-Saharan Africa is home to 11% of the world's population yet it accounts for the largest proportion of the global chronic disease burden . ConsequDespite the evidence to support integration of healthcare, replication and uptake of innovative primary healthcare programs has been slow and inequitable , 10. TheThe Kenyan health system has six levels of care. They include level 1, community services; level 2, dispensaries and clinics; level 3, health centers and maternity and nursing homes; level 4, Sub-County hospitals and medium-sized private hospitals; level 5, County referral hospitals and large private hospitals; and level 6, national referral hospitals and large private teaching hospitals , observation and focus group discussions (FGDs). The secondary data will involve analyses of routinely collected PIC4C care and project activity data including daily registers and the monthly reports. A SSI is a qualitative data generation method, which allows for a natural dialogue around a topic of interest. A predetermined list of questions is used to develop an interview schedule which is used to guide the discussion. There will be 48 SSI sessions involving County leaders including the CEC and Director Health, Non-communicable Diseases Coordinator). While the socio-demographics data will be collected using a structured questionnaire, the rest of the questions will be open-ended.The observation method generates qualitative data on specific activities of interest. In each County , we willThe RE-AIM framework will be used and we aim to interview the same study participants at each time point and recruit additional participants where appropriate. In Implementation focusses on the extent to which the PIC4C programs have been delivered as intended and appreciates any deviations/adaptations applied. This includes fidelity to the PIC4C activities, timing and costs. It also captures level of completeness and utilization of PIC4C interventions. The final dimension of the RE-AIM is maintenance, which considers sustained effectiveness of the PIC4C at the individual level and the sustained delivery at the institutional level in Busia and Trans Nzoia.The study participants will be clients, health care workers, and decision makers. The clients will include patients with diabetes, hypertension, cervical and breast cancers. Health care workers will include Community Health Promoters (CHPs), Community Health Volunteers (CHVs) and health care providers (being trainees and mentees). Decision makers are facility in-charges, Sub-county and County leaders. The FGD and the SSI participants will be selected purposefully in each county based on their health condition . The health care providers and decision makers will be selected in each county based on their cadre and level of their facility; County, Sub-County, Health Center or Dispensary. In addition, the sampling for the observations on patient reception and vital signs assessment in each County will be based on the facility level to ensure that each level is represented. The education and screening observation will be based on the number of community health promoters who are leading these sessions. The patient self-report surveys will be based on a sample size calculated to ensure a representation of the patients receiving care and treatment services for the four conditions under the PIC4C project in each of the Counties.Trained research assistants will recruit all study participants using predetermined inclusion criteria. For health care providers, they would have to be working in the designated County, Sub-County or health facility for at least 6 months, and be able to speak in English or Kiswahili.We aim to interview at least 3 individuals at the County level leadership. At Sub-County level, we aim to interview at least 9 individuals including the non-communicable disease (NCD) focal persons, Reproductive Health Coordinators, Medical Officers, Nursing officers, Health Records Officers and Pharmacists. At the facility level, we aim to interview at least 9 healthcare facility in-charges. We aim to have a mixed gender representation at all the recruitment levels .For the FGDs , the firPrior to beginning work in each county and each facility, approvals will be sought accordingly. A PIC4C local contact at the facilities and a research team member will meet with the relevant health facility leadership and discuss the process evaluation of the PIC4C project. At each health facility and prior to conducting consent, one of the RAs/research team members will recruit relevant HCPs, CHPs, and CHVs into the study. The PIC4C RA will approach the health worker individually, share with them the purpose of the data collection session, and confirm interest in participating. For those interested, the RA will schedule the session at a time convenient to the participant. For the patients, they will be identified from the PIC4C database based on their condition. Potential participants will be called and recruited by telephone 1–2 weeks before the FGD sessions that will be held in the nearest health facility and at times that are convenient to participants.The study will use both routinely collected clinic data  and data that will be specifically collected during the two waves. In wave one, the tools for data collection include: (1) Patient reception and vital signs' assessment checklist (Observation process mapping); (2) Education and screening observation checklist; (3) Written test/Random knowledge test for CHVs, CHPs and Clinicians; (4) Patient self-report/feedback forms; and (5) Health facility questionnaire. In wave two, all wave 1 tools will be administered. In addition, there will be SSIs with facility, Sub-County and county leaders; and FGDs with clients, HCPs, CHPs, and CHVs.Questionnaires will be administered at the facility, at baseline and end line, to compare availability of select drugs for hypertension and diabetes. Data will also capture the time of diagnosis to treatment for diabetes and hypertension care. For lost to follow-up, we shall use the return to clinic date. For those on medication, we shall check if they have defaulted 90 days from the last return to clinic. We shall also check for those on lifestyle modification.Trained research assistants will facilitate semi-structured interviews (SSIs), FGDs and observations. They will ensure all participants provide written consent before they participate in the evaluation. They will observe how patients are received, do process mapping during care, and report on how vital signs are assessed. They will also observe the education and screening activities. Regarding the FGDs, each session will be facilitated by a moderator and a scribe. The scribe will help the moderator by taking notes during the discussions. All sessions will be audio-recorded and conducted in a private space and at a time that will be convenient for participants. The questionnaire administration should take 40 min, while FGD and SSI sessions should take ~1 h.t-test to compare the mean scores for baseline and end line. The analysis will also include summaries of categorical variables, which include response frequencies for each questionnaire item. An appropriate cut-off for knowledge will be chosen so that characteristics of people who meet the threshold can be compared to those who do not, both at baseline and end line testing. Proportion of community members who accepted screening will be calculated as the total number of people who were screened divided by the total number of people who met the threshold. Linkage to care for diabetes and hypertension will be calculated as the total number of persons treated for diabetes and hypertension divided by the total number of persons referred after screening positive for diabetes and hypertension.As shown in Percentage of persons screened through each of the projects screening strategies who were linked to care will be calculated as the number of persons treated after referral from particular screening strategy divided by the total number of people treated after referral from screenings.Percentage of patients with controlled blood pressure will be calculated at end line for care levels 2, 3, and 4 as the proportion of patients >60 years with blood pressure (BP) below 150/90 and patients <60 years with BP below 140/90. The study will also report the percentage of patients with a drop in hemoglobin A1c at end line for levels 2, 3, and 4. Retention rates for treatment of diabetes and hypertension will be calculated as number of patients seen 90 days from their last expected clinic visit divided by the total number of patients in care. Drug affordability will be measured, at baseline and end line, as the percentage of patients able to buy a whole month supply of prescribed select medicines.The audio recordings will be transcribed and consequently coded using NVivo or a similar software. Prior to analysis, a research team member will listen to random sections of the recordings and compare them to the transcripts to verify accurate transcription. Then, three coders will look at the research questions, field notes and transcripts to familiarize themselves with the data. They will be guided by the research questions to develop a codebook through segmentation of thoughts found in the raw text. Each segment will be labeled with a descriptive code and definition that captures the ideas therein. The descriptive code labels will be assessed and similar patterns will be grouped together and labeled thematically. Analytic memos will track decision-making among coders as the codebook and themes are refined through subsequent stages of inductive development of themes. Quotes from transcripts will be used to provide vivid illustrations of the findings.This study was reviewed and approved by the Moi University College of Health Sciences and Moi Teaching and Referral Hospital institutional Ethics Committee. It was also approved by the National Commission for Science and Technology (NACOSTI) and endorsed by relevant County and health facility leadership. The objectives of the research will be clearly explained to potential participants. Participation will be voluntary and informed consent will be sought from each participant. Those who choose not to participate in the study will have their decision respected. Participants will also be allowed to withdraw from the study at any point, without any consequences. In order to protect participant privacy, the research team will not use any identifying information when managing data, running data analysis or writing the study reports. All data will be kept in lockable cabinets and passwords will be used for data saved on computers. Participants will be given the contact details of the study's principal investigator so that they can get more clarification on the evaluation—as necessary.The outcomes of the study will be made available to diverse stakeholders in Kenya, beginning with the communities of research and decision makers in Busia and Trans Nzoia. Specific dissemination for the communities and decision makers at the national, County and Sub-County levels will be carried out through mini workshops, community meetings, and government meetings. Findings and lessons learned will be provided and shared in various forms including written full reports, power point decks of cards, and policy briefs. In addition, study findings will be made available to the community of science through conferences and journal publications.Similar to other low and medium income countries (LMICs), Kenya is experiencing the burden of NCD. The aim of the PIC4C model was to identify people with the four conditions and ensure their timely referral to, treatment and management at the appropriate service level . In this paper, we have described the protocol and appendices being used to conduct a process evaluation of the PIC4C model. The Ministry of Health, AMPATH NCD clinics, and PIC4C research team have worked collaboratively to ensure the pilot model succeeds. The process evaluation is directly built upon the expectations of the PIC4C model and will provide valuable experiences and perspectives from recipient communities. The use of two waves of data collection allow for a better picture of the model for it reduces possibilities of biases or misleading information.This process evaluation has strengths and weaknesses. First, there are important lessons to be shared from the PIC4C process evaluation that are valuable to communities of research, local leadership, and broader academia. The PIC4C process evaluation protocol, methods, tools and study populations that were selected reflect what we find in other Kenyan counties and other similar LMICs. We therefore anticipate that this protocol is relevant to other settings. Secondly, the process evaluation is helping us illuminate aspects of the PIC4C Model that have worked well. There were also challenges and limitations that we have been experiencing. For instance, it would have been better to have a three-level monitoring and evaluation process: baseline, midterm, and post-intervention. This would have provided a better portrayal of inputs, all community and health facility activities, and associated outputs. However, due to the COVID-19 pandemic, the mid-term wave was not feasible. We therefore missed some opportunities during the implementation phase to observe and use resultant findings to inform users and the PIC4C team. Nonetheless, this process evaluation has been providing data and evidence that is useful for the current PIC4C pilot, and future anticipated scale ups of integrated care for NCDs in Kenya and beyond.The studies involving human participants were reviewed and approved by Moi University College of Health Sciences and Moi Teaching and Referral Hospital institutional Ethics Committee, Eldoret. The patients/participants provided their written informed consent to participate in this study.VN, JK, and KT contributed to the conceptualization of the project and PIC4C process evaluation. VN, JK, HK, KT, GG, and OL contributed to the development of data collection materials, recruitment of participants, and data collection. VN, HK, and BM drafted the manuscript, and all authors edited and approved the final draft.This project was supported by the World Bank under the terms of grant number World Bank TFA5636 and Access Accelerated Initiative.Contents are the authors' sole responsibility and do not necessarily represent interpretations by national, County, or funding stakeholders.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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