Efficacy of the FDA nozzle benchmark and the lattice Boltzmann method for the analysis of biomedical flows in transitional regime

Flows through medical devices as well as in anatomical vessels despite being at moderate Reynolds number may exhibit transitional or even turbulent character. In order to validate numerical methods and codes used for biomedical flow computations, the US Food and Drug Administration (FDA) established an experimental benchmark, which was a pipe with gradual contraction and sudden expansion representing a nozzle. The experimental results for various Reynolds numbers ranging from 500 to 6500 were publicly released. Previous and recent computational investigations of flow in the FDA nozzle found limitations in various CFD approaches and some even questioned the adequacy of the benchmark itself. This communication reports the results of a lattice Boltzmann method (LBM) – based direct numerical simulation (DNS) approach applied to the FDA nozzle benchmark for transitional cases of Reynolds numbers 2000 and 3500. The goal is to evaluate if a simple off the shelf LBM would predict the experimental results without the use of complex models or synthetic turbulence at the inflow. LBM computations with various spatial and temporal resolutions are performed—in the extremities of 45 million to 2.88 billion lattice cells—executed respectively on 32 CPU cores of a desktop to more than 300,000 cores of a modern supercomputer to explore and characterize miniscule flow details and quantify Kolmogorov scales. The LBM simulations transition to turbulence at a Reynolds number 2000 like the FDA’s experiments and acceptable agreement in jet breakdown locations, average velocity, shear stress, and pressure is found for both the Reynolds numbers.

Graphical Abstract

iPLEDGE Must Abstain from Abstinence

Isotretinoin has unmatched efficacy in the treatment of acne. However, because isotretinoin is a teratogen that can cause profound birth defects, the iPLEDGE program regulates the drug's distribution in the United States. To minimize fetal exposure to isotretinoin, the program requires that female patients capable of becoming pregnant use two forms of contraception or commit to abstinence while using this therapy. This manuscript argues that iPLEDGE should be revised to remove abstinence as an acceptable contraceptive option in the face of evidence that disputes its efficacy. All patients, regardless of reported sexual activity, should be required to use data-proven contraception. Potential benefits of the proposed change (iPLEDGE-R) include reducing the number of isotretinoin pregnancies, increasing patient privacy protection, and standardizing patient care. Further investigation needs to guide additional strategies to achieve the program's public health goal; however, the ethical and pragmatic advantages of iPLEDGE-R merit consideration.

Amplatzer Piccolo Occluder clinical trial for percutaneous closure of the patent ductus arteriosus in patients ≥700 grams

Objectives

Characterize the safety and effectiveness of the Amplatzer Piccolo Occluder for patent ductus arteriosus (PDA) closure.

Background

The presence of a hemodynamically significant PDA has been associated with an increased risk of morbidity and mortality in children born premature.

Methods

This was a single arm, prospective, multicenter, non‐randomized study to evaluate the Amplatzer Piccolo Occluder to treat PDA in patients ≥700 g. From June 2017 to February 2019, 200 patients were enrolled at nine centers, with 100 patients weighing ≤2 kg. Primary effectiveness endpoint was the rate of PDA closure at 6‐month follow‐up. Primary safety endpoint was the rate of major complications through 6 months. Secondary endpoint was rate of significant pulmonary or aortic obstruction through 6 months' follow‐up.

Results

The implant success rate was 95.5% (191/200) overall and 99% in patients ≤2 kg (99/100). The primary effectiveness endpoint was achieved in 99.4% of implanted patients. Four patients experienced a primary safety endpoint event (2 transfusions, 1 hemolysis, and 1 aortic obstruction). There were no branch pulmonary artery obstructions. Five patients, all ≤2 kg, were noted to have worsening of tricuspid regurgitation (TR) after the procedure. None of the TR incidences manifested clinically. The Amplatzer Piccolo Occluder received FDA approval in January 2019 and became the first device approved for PDA closure in patients ≥700 g.

Conclusions

This study supports the safety and effectiveness of the Amplatzer Piccolo Occluder, particularly in patients between 700 g and 2 kg where there is currently a significant unmet need in the United States. ClinicalTrials.gov identifier: NCT03055858.

Revision of a Tronzo Total Hip Arthroplasty

Revision total hip arthroplasty presents many challenges in regards to reconstructing or managing large amounts of bone loss and soft-tissue damage. Modern revision components, as well as techniques, have helped to address these challenges; however, the goal of any surgery is to provide the least amount of surgery with the most successful outcome. This case highlights a 74-year-old man with a Tronzo total hip arthroplasty placed over 50 years prior. He presented with subjective hip instability and radiographs demonstrating disassociation of the modular component. In an attempt to avoid more extensive and costly surgery, a custom-made all-polyethylene femoral head was used. This case illustrates the revision of likely one of the few Tronzo total hips remaining and the utility of obtaining a compassionate-use clearance from the Food and Drug Administration to create a custom piece, to minimize potential morbidity and mortality from extensive hip revision surgery.

FDA Approvals and Consensus Guidelines for Botulinum Toxins in the Treatment of Dystonia

In 2016, the American Academy of Neurology (AAN) published practice guidelines for botulinum toxin (BoNT) in the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache. This article, focusing on dystonia, provides context for these guidelines through literature review. Studies that led to Food and Drug Administration (FDA) approval of each toxin for dystonia indications are reviewed, in addition to several studies highlighted by the AAN guidelines. The AAN guidelines for the use of BoNT in dystonia are compared with those of the European Federation of the Neurological Societies (EFNS), and common off-label uses for BoNT in dystonia are discussed. Toxins not currently FDA-approved for the treatment of dystonia are additionally reviewed. In the future, additional toxins may become FDA-approved for the treatment of dystonia given expanding research in this area.

Current regulatory approaches for accessing potential COVID-19 therapies

This commentary aims to elaborate challenges in the regulatory approaches for accessing and investigating COVID-19 potential therapies either with off-label use, compassionate use, emergency use or for clinical trials. Since no therapies have been formally approved and completely effective and safe to date, the best clinical choice is acquired only after consistent and fair communication and collaboration between licensed clinicians, researchers, regulatory authorities, manufacturers and patients.

The End of the Road for the YSI 2300 Analyzer: Where Do We Go Now?

Production of the YSI 2300 STAT PLUS Glucose and l-Lactate Analyzer (YSI Incorporated, Yellow Springs, OH, United States) has been discontinued. This benchtop instrument is the most widely used device for determining the accuracy of products that measure blood glucose and interstitial fluid glucose. An alternate comparator instrument must now be identified by the diabetes diagnostics industry. The available products should be reviewed by parties interested in accurate, fast, low-cost comparator benchtop, or portable (nonstrip) methods using small sample volumes with good ease-of-use and human factors. Stakeholders include glucose monitor manufacturers, test labs, clinical chemists, diabetes clinicians, professional organizations, and regulators. This article presents features of eleven possible alternative instruments to be considered as comparator methods for measuring the accuracy of glucose monitors.

Hydrogels in the clinic

Injectable hydrogels are one of the most widely investigated and versatile technologies for drug delivery and tissue engineering applications. Hydrogels' versatility arises from their tunable structure, which has been enabled by considerable advances in fields such as materials engineering, polymer science, and chemistry. Advances in these fields continue to lead to invention of new polymers, new approaches to crosslink polymers, new strategies to fabricate hydrogels, and new applications arising from hydrogels for improving healthcare. Various hydrogel technologies have received regulatory approval for healthcare applications ranging from cancer treatment to aesthetic corrections to spinal fusion. Beyond these applications, hydrogels are being studied in clinical settings for tissue regeneration, incontinence, and other applications. Here, we analyze the current clinical landscape of injectable hydrogel technologies, including hydrogels that have been clinically approved or are currently being investigated in clinical settings. We summarize our analysis to highlight key clinical areas that hydrogels have found sustained success in and further discuss challenges that may limit their future clinical translation.

Survival outcomes for robotic-assisted laparoscopy versus traditional laparoscopy in clinical stage I epithelial ovarian cancer

BACKGROUND

The US Food and Drug Administration recently called for studies addressing long-term survival after robotic-assisted laparoscopy in oncologic settings. Long-term clinical outcomes of robotic-assisted laparoscopy among ovarian cancer patients are understudied.

OBJECTIVE(S)

To investigate the long-term mortality of robotic-assisted laparoscopy compared to traditional laparoscopy for clinical stage I epithelial ovarian cancer.

MATERIALS AND METHODS

Using data from the National Cancer Database, we identified a total of 1901 patients who received minimally invasive surgery (ie, robotic-assisted laparoscopy or traditional laparoscopy) for clinical stage I epithelial ovarian cancer between 2010 and 2014. Multivariable logistic or linear regression analyses were conducted to evaluate the short-term outcomes, including conversion-to-open surgery, number of lymph nodes examined, length of hospitalization, unplanned 30-day readmission, and 30- and 90-day mortality. Multivariable Cox proportional hazards models were used to derive adjusted hazard ratios and 95% confidence intervals for 1-, 3-, and 5-year total mortality associated with surgical approaches. Covariates adjusted for included age, tumor size and upstaging, number of lymph nodes evaluated, time from diagnosis to surgery, length of hospitalization, histologic subtype, insurance status, region, distance to care, surgical procedure type, and hospital experience with these procedures.

RESULTS

Compared to traditional laparoscopy, robotic-assisted laparoscopy was less likely to result in conversion-to-open surgery (conversion rate: 7.2% versus 17.9%, P < .001; adjusted odds ratio, 0.49; 95% confidence interval, 0.33-0.73). In multivariable analyses, there were no significant differences in survival between robotic-assisted laparoscopy- and traditional laparoscopy-treated patients. Compared with traditional laparoscopy, the adjusted hazard ratios for 1-, 3-, and 5-year mortality were 0.97 (95% confidence interval, 0.43-2.18), 0.68 (95% confidence interval, 0.43-1.08), and 0.78 (95% confidence interval, 0.53-1.16), respectively.

CONCLUSION(S)

Robotic-assisted laparoscopy had comparable overall mortality in comparison to traditional laparoscopy when treating clinical stage I epithelial ovarian cancer.

Esketamine clinical trials: reply to Maju et al

Maju et al. provided clarifications on important and controversial issues related to esketamine clinical trial data, in response to a vivid debate triggered by the marketing authorisation recently granted by this new medicine. In this commentary, we reply to their comments attempting to critically discuss the evidence base needed to obtain regulatory approval.

Role of SLC transporters in toxicity induced by anticancer drugs

INTRODUCTION

. Membrane transporters are integral to the maintenance of cellular integrity of all tissue and cell types. While transporters play an established role in the systemic pharmacokinetics of therapeutic drugs, tissue specific expression of uptake transporters can serve as an initiating mechanism that governs the accumulation and impact of cytotoxic drugs.

AREAS COVERED

. This review provides an overview of organic cation transporters as determinants of chemotherapy-induced toxicities. We also provide insights into the recently updated FDA guidelines for in vitro drug interaction studies, with a particular focus on the class of tyrosine kinase inhibitors as perpetrators of transporter-mediated drug interactions.

EXPERT OPINION

. Studies performed over the last few decades have highlighted the important role of basolateral uptake and apical efflux transporters in the pathophysiology of drug-induced organ damage. Increased understanding of the mechanisms that govern the accumulation of cytotoxic drugs has provided insights into the development of novel strategies to prevent debilitating toxicities. Furthermore, we argue that current regulatory guidelines provide inadequate recommendations for in vitro studies to identify substrates or inhibitors of drug transporters. Therefore, the translational and predictive power of FDA-approved drugs as modulators of transport function remains ambiguous and warrants further revision of the current guidelines.

Off-Label studies on anakinra in dermatology: a review

Purpose: Anakinra (Kineret^®) is an interleukin-1 receptor antagonist (IL-1Ra) FDA approved for use in rheumatoid arthritis and in neonatal-onset multisystem inflammatory disease (NOMID). It has been used off-label for a variety of dermatologic conditions. A review of the available studies and cases of these off-label uses would be valuable to the dermatologist considering alternative treatments for these oftentimes poorly studied conditions.Materials and methods: The PubMed/MEDLINE, EMBASE, Scopus, and ClinicalTrials.gov databases were searched with the term 'anakinra.' Results were manually screened to identify published data on off-label uses of anakinra in dermatologic conditions and systemic conditions with prominent dermatologic manifestations.Results: Anakinra appears to show efficacy for numerous dermatologic conditions, with the strongest evidence for hidradenitis suppurativa, Bechet's disease, Muckle-Wells syndrome, and SAPHO syndrome. Case reports and case series data are available for numerous other dermatologic conditions.Conclusion: Anakinra is a potential option for patients with certain difficult-to-treat dermatologic diseases, given its relatively benign adverse effect profile and its effectiveness in a wide array of conditions. Overall, anakinra appears to be a promising option in the treatment of numerous dermatologic inflammatory conditions refractory to first line therapies, but further and higher-quality data is needed to clarify its therapeutic role.

Assessing Animal Models of Bacterial Pneumonia Used in Investigational New Drug Applications for the Treatment of Bacterial Pneumonia

Animal models of bacterial infection have been widely used to explore the in vivo activity of antibacterial drugs. These data are often submitted to the U.S. Food and Drug Administration to support human use in an investigational new drug application (IND). To better understand the range and scientific use of animal models in regulatory submissions, a database was created surveying recent pneumonia models submitted as part of IND application packages. The IND studies were compared to animal models of bacterial pneumonia published in the scientific literature over the same period of time. In this review, we analyze the key experimental design elements, such as animal species, immune status, pathogens selected, and route of administration, and study endpoints.

FDA-Approved Drugs Efavirenz, Tipranavir, and Dasabuvir Inhibit Replication of Multiple Flaviviruses in Vero Cells

Vector-borne flaviviruses (VBFs) affect human health worldwide, but no approved drugs are available specifically to treat VBF-associated infections. Here, we performed in silico screening of a library of U.S. Food and Drug Administration-approved antiviral drugs for their interaction with Zika virus proteins. Twelve hit drugs were identified by the docking experiments and tested in cell-based antiviral assay systems. Efavirenz, tipranavir, and dasabuvir at micromolar concentrations were identified to inhibit all VBFs tested; i.e., two representatives of mosquito-borne flaviviruses (Zika and West Nile viruses) and one representative of flaviviruses transmitted by ticks (tick-borne encephalitis virus). The results warrant further research into these drugs, either individually or in combination, as possible pan-flavivirus inhibitors.

Awareness of "The Real Cost" Campaign Among US Middle and High School Students: National Youth Tobacco Survey, 2017

OBJECTIVES

Monitoring awareness of a public education campaign can help to better understand the extent of sustained population-level exposure to the campaign. We examined unaided awareness (awareness that does not include a visual image to remind the respondent of the campaign or advertisement) and correlates of unaided awareness of "The Real Cost," a national youth tobacco education campaign developed by the US Food and Drug Administration and implemented in 2014.

METHODS

This secondary analysis examined unaided campaign awareness by using data from the 2017 National Youth Tobacco Survey, a nationally representative school-based sample of young persons aged 9-19 years (n = 17 269) surveyed approximately 3 years after campaign launch. We compared unaided campaign awareness among various cigarette user groups (experimenters, susceptible nonsmokers, current or former smokers, and nonsusceptible nonsmokers). We examined associations between unaided campaign awareness and demographic and tobacco-related correlates, overall and by cigarette user group.

RESULTS

Three years after "The Real Cost" campaign was launched, most middle and high school students (58.5%) still reported unaided campaign awareness. Of 17 269 middle and high school students in the sample, 62.0% of susceptible nonsmokers and 64.5% of experimenters reported unaided campaign awareness. Among susceptible nonsmokers, unaided campaign awareness differed by age and race/ethnicity and was higher among students with greater tobacco-related harm perceptions (vs lower harm perceptions) and exposure to pro-tobacco marketing (vs no exposure).

CONCLUSIONS

Future surveillance and research could examine awareness of "The Real Cost" campaign and effects of the campaign on young persons' knowledge, attitudes, and beliefs to further assess the public health impact of tobacco prevention campaigns.

Translating innovation in biomedical research: Design and delivery of a competency-based regulatory science course

As the pace of biomedical innovation rapidly evolves, there is a need to train researchers to understand regulatory science challenges associated with clinical translation. We describe a pilot course aimed at addressing this need delivered jointly through the Mayo Clinic Center for Clinical and Translational Science and the Yale-Mayo Center for Excellence in Regulatory Science and Innovation. Course design was informed by the Association for Clinical and Translational Science's Regulatory Science Working Group's competencies. The course used didactic, case-, and problem-based learning sessions to expose students to regulatory science concepts. Course evaluation focused on student satisfaction and learning. A total of 25 students enrolled in the first two course deliveries. Students represented several disciplines and career stages, from predoctoral to faculty. Students reported learning "an incredible amount" (7/19, 36.8%) or "a lot" (9/19, 47.4%); this was reflected in individual coursework and their course evaluations. Qualitative feedback indicated that assignments that challenged them to apply the content to their own research were appreciated. The heterogeneity of students enrolled, coupled with assessments and course evaluations, supports the statement that there is a growing need and desire for regulatory science-focused curricula. Future research will determine the long-term impact.

Endpoints in Heart Failure Drug Development: History and Future

Heart failure (HF) patients experience a high burden of symptoms and functional limitations, and morbidity and mortality remain high despite successful therapies. The majority of HF drugs in the United States are approved for reducing hospitalization and mortality, while only a few have indications for improving quality of life, physical function, or symptoms. Patient-reported outcomes that directly measure patient's perception of health status (symptoms, physical function, or quality of life) are potentially approvable endpoints in drug development. This paper summarizes the history of endpoints used for HF drug approvals in the United States and reviews endpoints that measure symptoms, physical function, or quality of life in HF patients.

Evaluating the evidence behind the surrogate measures included in the FDA's table of surrogate endpoints as supporting approval of cancer drugs

BACKGROUND

In July 2018, the FDA first published a table listing all surrogate measures that it has used, and may accept for future use, in regulatory approval. However, the strength of surrogacy for those measures was not formally assessed. Using the case example of breast cancer, we aimed to evaluate the strength of correlation of surrogate measures listed in the FDA's Table with overall survival.

METHODS

This cross-sectional study of the FDA's Table of Surrogate Endpoints was conducted in May 2019. All surrogate measures listed in the FDA table as appropriate for accelerated or regular approval for breast cancer were extracted. We identified studies evaluating the correlation of treatment benefit in the surrogate with treatment benefit in overall survival and extracted results from the correlation analysis.

FINDINGS

Five surrogate endpoints were listed for breast cancer in the FDA website: pathological complete response rates (pCR), event-free survival (EFS), disease-free survival (DFS), objective response rates (ORR), and progression-free survival (PFS), of which pCR was listed as appropriate only for accelerated approval, while the rest were considered appropriate for accelerated or regular approval. No correlation study evaluated the correlation of treatment effects on EFS with that on OS. The results from correlation studies evaluating pCR, DFS, ORR, and PFS suggest that the treatment effects on none of these surrogate measures were strongly correlated with treatment effects on OS (r<0.85 or R²  < 0.7, except for DFS in HER2 positive early breast cancer (R²  = 0.75).

INTERPRETATION

Using breast cancer as an example, we evaluated the underlying evidence for the surrogate endpoints for solid tumors listed in the FDA's Table of Surrogate Endpoints and found weak or missing correlations of treatment effects on these surrogates with treatment effects on OS . Surrogate measures should be predictive of clinical benefit to be useful in supporting regular FDA approval.

FUNDING

Work on this project was funded by the Arnold Ventures. Dr. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2019

OBJECTIVE

To review new devices and drugs relevant to otolaryngology-head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2019.

DATA SOURCES

Approval notifications for 2019 were extracted from the ENT (ear, nose, and throat) and general and plastic surgery sections of the FDA's medical devices and therapeutics listings.

REVIEW METHODS

New therapeutics and medical devices identified from the query were analyzed by members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee. Technologies were assessed by 2 independent reviewers to ascertain relevance to otolaryngology, prioritized, and classified to subspecialty field with critical review based on extant scientific literature.

CONCLUSIONS

Query of the FDA drug and device database returned 105 ENT devices (50 cleared, 55 with premarket approval, and 0 de novo), 543 general and plastic surgery devices (372 cleared, 170 with premarket approval, and 1 de novo), and 46 new otolaryngology-relevant drug approvals that occurred in 2019. Advances spanned all subspecialty areas with otology predominating, primarily due to hearing-related technologies. While scientific evidence was available for all new devices, there was significant heterogeneity in rigor of supporting scientific data.

IMPLICATIONS FOR PRACTICE

Technological and pharmaceutical innovation is an important catalyst for advances in the surgical specialties. Familiarity with new devices and therapeutics in otolaryngology-head and neck surgery ensures that clinicians keep abreast of developments with potential to improve prevailing standards of care.

The Last Mile: DSCSA Solution Through Blockchain Technology: Drug Tracking, Tracing, and Verification at the Last Mile of the Pharmaceutical Supply Chain with BRUINchain

Purpose

As part of the FDA's DSCSA Pilot Project Program, UCLA and its solution partner, LedgerDomain (collectively referred to as the team hereafter), focused on building a complete, working blockchain-based system, BRUINchain, which would meet all the key objectives of the Drug Supply Chain Security Act (DSCSA) for a dispenser operating solely on commercial off-the-shelf (COTS) technology.

Methods

The BRUINchain system requirements include scanning the drug package for a correctly formatted 2D barcode, flagging expired products, verifying the product with the manufacturer, and quarantining suspect and illegitimate products at the last mile: pharmacist to patient, the most complex area of the drug supply chain.The authors demonstrate a successful implementation where product-tracing notifications are sent automatically to key stakeholders, resulting in enhanced timeliness and reduction in paperwork burden. At the core of this effort was a blockchain-based solution to track and trace changes in custody of drug. As an immutable, time-stamped, near-real-time (50-millisecond latency), auditable record of transactions, BRUINchain makes it possible for supply chain communities to arrive at a single version of the truth. BRUINchain was tested using real data on real caregivers administering life-saving medications to real patients at one of the busiest pharmacies in the United States.

Results

In addition to communicating with the manufacturer directly for verification, BRUINchain also initiated suspect product notifications. During the study, a 100% success rate was observed for scanning, expiration detection, and counterfeit detection; and paperwork reduction from approximately 1 hour to less than a minute.

Conclusions

By automatically interrogating the manufacturer's relational database with our blockchain-based system, our results indicate a projected DSCSA compliance cost of 17 cents per unit, and potentially much more depending on regulatory interpretation and speed of verification. We project that this cost could be reduced with manufacturers' adoption of a highly performant, fully automated end-to-end system based on digital ledger technology (DLT). During an examination of the interoperability of such a system, we elaborate on its capacity to enable verification in real time without keeping humans in the loop, the key feature driving lower compliance cost. With 4.2 billion prescriptions being dispensed each year in the United States, DLT would not only reduce the projected per-unit cost to 13 cents per unit (saving $183 million in annual labor costs), but also serve as a major bulwark against bad or fraudulent transactions, reduce the need for safety stock, and enhance the detection and removal of potentially dangerous drugs from the drug supply chain to protect US consumers.

Review of Indications of FDA-Approved Immune Checkpoint Inhibitors per NCCN Guidelines with the Level of Evidence

Cancer is associated with higher morbidity and mortality and is the second leading cause of death in the US. Further, in some nations, cancer has overtaken heart disease as the leading cause of mortality. Identification of molecular mechanisms by which cancerous cells evade T cell-mediated cytotoxic damage has led to the modern era of immunotherapy in cancer treatment. Agents that release these immune brakes have shown activity to recover dysfunctional T cells and regress various cancer. Both cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and Programmed Death-1 (PD-1) play their role as physiologic brakes on unrestrained cytotoxic T effector function. CTLA-4 (CD 152) is a B7/CD28 family; it mediates immunosuppression by indirectly diminishing signaling through the co-stimulatory receptor CD28. Ipilimumab is the first and only FDA-approved CTLA-4 inhibitor; PD-1 is an inhibitory transmembrane protein expressed on T cells, B cells, Natural Killer cells (NKs), and Myeloid-Derived Suppressor Cells (MDSCs). Programmed Death-Ligand 1 (PD-L1) is expressed on the surface of multiple tissue types, including many tumor cells and hematopoietic cells. PD-L2 is more restricted to hematopoietic cells. Blockade of the PD-1 /PDL-1 pathway can enhance anti-tumor T cell reactivity and promotes immune control over the cancerous cells. Since the FDA approval of ipilimumab (human IgG1 k anti-CTLA-4 monoclonal antibody) in 2011, six more immune checkpoint inhibitors (ICIs) have been approved for cancer therapy. PD-1 inhibitors nivolumab, pembrolizumab, cemiplimab and PD-L1 inhibitors atezolizumab, avelumab, and durvalumab are in the current list of the approved agents in addition to ipilimumab. In this review paper, we discuss the role of each immune checkpoint inhibitor (ICI), the landmark trials which led to their FDA approval, and the strength of the evidence per National Comprehensive Cancer Network (NCCN), which is broadly utilized by medical oncologists and hematologists in their daily practice.

Pharmaceutical Ethics and Grassroots Activism in the United States: A Social History Perspective

Women's health activists laid the groundwork for passage of the law that created the U.S. Food and Drug Administration in 1906. The pharmaceutical and food industries fought regulatory reforms then and continue to do so now. We examine public health activism in the Progressive Era, the postwar era and the present day. The women's health movement began in the 1960s, and criticized both the pharmaceutical industry and the medical establishment. In the 1990s, patient advocacy groups began accepting industry funds; thousands of commercially-funded groups now dominate the advocacy landscape. As pharma funding became normalized, concerns arose regarding a) the lack of transparency and public accountability regarding funding, b) the distortion of groups' agendas, and c) the ability of pharma-funded groups to dominate the discourse and override less well-resourced patient and health advocacy groups. Although industry-funded groups argue that funding allows them to provide useful services, the trade-off in health risks, exorbitant prices and distorted information is far too high. Sincerity is beside the point; patients and the industry have differing interests when it comes to drug safety and efficacy, drug information and drug prices. A growing resistance movement is asserting the values of its activist predecessors and opposing the prevailing culture of pharma-funded advocacy.

Expanded FDA regulation of health and wellness apps

This paper argues that the Food and Drug Administration's (FDA) policy for health and wellness apps is ethically problematic. Currently, the FDA does not regulate health and wellness apps that are not intended for medical use. As a result of this hands-off policy, preventing harm to consumers is left primarily to developers and app marketplaces. We argue that the FDA's duties to prevent harm and maintain accountability to the American public require that they play a much stronger role. We also discuss concerns about efficiency and fostering innovation, and argue that while they should help shape FDA regulation of health and wellness apps, they do not justify complete absence of FDA involvement.

Integrating the Voice of the Patient Into the Medical Device Regulatory Process Using Patient Preference Information

The US Food and Drug Administration is one of several US and global agencies making strides to incorporate patient preference information (PPI) into its decision making. PPI has been included in 5 completed medical device marketing decisions to date. Its usage is not more widespread because of uncertainty about how to design "fit-for-purpose" patient preference studies and a lack of standards for the choice of preference elicitation methods, among other reasons. To advance the application of PPI to decision making about medical devices, the Food and Drug Administration has published a guidance document, "Patient Preference Information-Voluntary Submission, Review in Premarket Approval Applications, Humanitarian Device Exemption Applications, and De Novo Requests, and Inclusion in Decision Summaries and Device Labeling." This article discusses key concepts in the guidance document, in addition to providing lessons learned from the use of PPI for medical device regulatory applications to date and identifying new opportunities to leverage PPI to elevate the patient voice in the medical device product life cycle.