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Toni E, Ayatollahi H, Abbaszadeh R, Fotuhi Siahpirani A. Adverse Drug Reactions in Children with Congenital Heart Disease: A Scoping Review. Paediatr Drugs 2024; 26:519-553. [PMID: 39044096 DOI: 10.1007/s40272-024-00644-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Congenital heart disease (CHD) is one of the leading causes of death. Safe and timely medical interventions, especially in children, can prolong their survival. The drugs prescribed for children with CHD are mainly based on the outcomes of drug therapy in adults with cardiovascular diseases, and their adverse drug reactions (ADRs) might be different. Therefore, the aim of this study was to investigate ADRs in children with CHD. METHODS This was a scoping review conducted in 2023. PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, ProQuest, and Google Scholar databases were searched. All studies that reported ADRs for children with CHD and were published in English by 1 November 2023 were included in this study. Finally, the results were reported using a content analysis method. RESULTS A total of 87 articles were included in the study. The results showed that symptoms/signs/clinical findings, and cardiovascular disorders were the most common ADRs reported in children with CHD. The results also showed that most of the ADRs were reported for prostaglandin E1, amiodarone, prostaglandin E2, dexmedetomidine, and captopril, respectively. CONCLUSION The review underscores the wide array of ADRs in children with CHD, particularly in antiarrhythmics, diuretics, beta-blockers, anticoagulants, and vasodilators, which affected cardiovascular, respiratory, endocrine, metabolic, genitourinary, gastrointestinal, and musculoskeletal systems. Tailored treatment is imperative, considering individual patient characteristics, especially in the vulnerable groups. Further research is essential for optimizing dosing, pharmacogenetics, and alternative therapies to enhance patient outcomes in CHD management.
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Affiliation(s)
- Esmaeel Toni
- Medical Informatics, Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Haleh Ayatollahi
- Medical Informatics, Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran.
| | - Reza Abbaszadeh
- Pediatric Cardiology, Heart Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Fotuhi Siahpirani
- Department of Bioinformatics, Institute of Biochemistry and Biophysics (IBB), University of Tehran, Tehran, Iran
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2
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Guerlich K, Patro-Golab B, Dworakowski P, Fraser AG, Kammermeier M, Melvin T, Koletzko B. Evidence from clinical trials on high-risk medical devices in children: a scoping review. Pediatr Res 2024; 95:615-624. [PMID: 37758865 PMCID: PMC10899114 DOI: 10.1038/s41390-023-02819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/31/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Meeting increased regulatory requirements for clinical evaluation of medical devices marketed in Europe in accordance with the Medical Device Regulation (EU 2017/745) is challenging, particularly for high-risk devices used in children. METHODS Within the CORE-MD project, we performed a scoping review on evidence from clinical trials investigating high-risk paediatric medical devices used in paediatric cardiology, diabetology, orthopaedics and surgery, in patients aged 0-21 years. We searched Medline and Embase from 1st January 2017 to 9th November 2022. RESULTS From 1692 records screened, 99 trials were included. Most were multicentre studies performed in North America and Europe that mainly had evaluated medical devices from the specialty of diabetology. Most had enrolled adolescents and 39% of trials included both children and adults. Randomized controlled trials accounted for 38% of the sample. Other frequently used designs were before-after studies (21%) and crossover trials (20%). Included trials were mainly small, with a sample size <100 participants in 64% of the studies. Most frequently assessed outcomes were efficacy and effectiveness as well as safety. CONCLUSION Within the assessed sample, clinical trials on high-risk medical devices in children were of various designs, often lacked a concurrent control group, and recruited few infants and young children. IMPACT In the assessed sample, clinical trials on high-risk medical devices in children were mainly small, with variable study designs (often without concurrent control), and they mostly enrolled adolescents. We provide a systematic summary of methodologies applied in clinical trials of medical devices in the paediatric population, reflecting obstacles in this research area that make it challenging to conduct adequately powered randomized controlled trials. In view of changing European regulations and related concerns about shortages of high-risk medical devices for children, our findings may assist competent authorities in setting realistic requirements for the evidence level to support device conformity certification.
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Affiliation(s)
- Kathrin Guerlich
- LMU-Ludwig Maximilians Universität Munich, Division of Metabolic and Nutritional Medicine, Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, Munich, Germany
- Child Health Foundation - Stiftung Kindergesundheit, c/o Dr. von Hauner Children's Hospital, Munich, Germany
| | - Bernadeta Patro-Golab
- LMU-Ludwig Maximilians Universität Munich, Division of Metabolic and Nutritional Medicine, Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, Munich, Germany
| | | | - Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, Wales, UK
| | - Michael Kammermeier
- LMU-Ludwig Maximilians Universität Munich, Division of Metabolic and Nutritional Medicine, Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, Munich, Germany
| | - Tom Melvin
- Department of Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Berthold Koletzko
- LMU-Ludwig Maximilians Universität Munich, Division of Metabolic and Nutritional Medicine, Department of Pediatrics, Dr. von Hauner Children's Hospital, LMU University Hospital, Munich, Germany.
- Child Health Foundation - Stiftung Kindergesundheit, c/o Dr. von Hauner Children's Hospital, Munich, Germany.
- European Academy of Paediatrics, Brussels, Belgium.
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3
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Salameh S, Ogueri V, Posnack NG. Adapting to a new environment: postnatal maturation of the human cardiomyocyte. J Physiol 2023; 601:2593-2619. [PMID: 37031380 PMCID: PMC10775138 DOI: 10.1113/jp283792] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/16/2023] [Indexed: 04/10/2023] Open
Abstract
The postnatal mammalian heart undergoes remarkable developmental changes, which are stimulated by the transition from the intrauterine to extrauterine environment. With birth, increased oxygen levels promote metabolic, structural and biophysical maturation of cardiomyocytes, resulting in mature muscle with increased efficiency, contractility and electrical conduction. In this Topical Review article, we highlight key studies that inform our current understanding of human cardiomyocyte maturation. Collectively, these studies suggest that human atrial and ventricular myocytes evolve quickly within the first year but might not reach a fully mature adult phenotype until nearly the first decade of life. However, it is important to note that fetal, neonatal and paediatric cardiac physiology studies are hindered by a number of limitations, including the scarcity of human tissue, small sample size and a heavy reliance on diseased tissue samples, often without age-matched healthy controls. Future developmental studies are warranted to expand our understanding of normal cardiac physiology/pathophysiology and inform age-appropriate treatment strategies for cardiac disease.
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Affiliation(s)
- Shatha Salameh
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
| | - Vanessa Ogueri
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Nikki Gillum Posnack
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
- Department of Pediatrics, George Washington University, Washington, DC, USA
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4
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Madrigal VN, Feltman DM, Leuthner SR, Kirsch R, Hamilton R, Dokken D, Needle J, Boss R, Lelkes E, Carter B, Macias E, Bhombal S. Bioethics for Neonatal Cardiac Care. Pediatrics 2022; 150:189885. [PMID: 36317974 DOI: 10.1542/peds.2022-056415n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications. METHODS Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice. RESULTS We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions. CONCLUSIONS We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.
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Affiliation(s)
- Vanessa N Madrigal
- Department of Pediatrics, Division of Critical Care Medicine and Pediatric Ethics Program, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Dalia M Feltman
- NorthShore University HealthSystem Evanston Hospital, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Steven R Leuthner
- Departments of Pediatrics and Bioethics, Division of Neonatology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Roxanne Kirsch
- Department of Critical Care, Division Cardiac Critical Care Medicine; Department of Bioethics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rekha Hamilton
- Mednax Inc. Cook Children's Medical Center, Fort Worth, Texas
| | - Deborah Dokken
- Family Leader and Staff Member, Institute for Patient and Family-Centered Care, Bethesda, Maryland
| | - Jennifer Needle
- Department of Pediatrics and the Center for Bioethics, University of Minnesota, Minneapolis, Minnesota
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland
| | - Efrat Lelkes
- Department of Pediatrics, Divisions of Critical Care Medicine and Palliative Medicine, Bioethics, University of California San Francisco, San Francisco, California
| | - Brian Carter
- Departments of Humanities and Pediatrics, Division of Neonatology and Bioethics Center, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Eduardo Macias
- Department of Pediatrics, Division of Pediatric Cardiology. University Hospital, University of Texas, San Antonio, Texas
| | - Shazia Bhombal
- Department of Pediatrics, Lucile Packard Children's Hospital. Stanford, Palo Alto, California
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5
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Kreutzer J, Armstrong AK, Rome JJ, Zellers TM, Balzer DT, Zampi JD, Cabalka AK, Javois AJ, Turner DR, Gray RG, Moore JW, Weng S, Jones TK, Khan DM, Vincent JA, Hellenbrand WE, Cheatham JP, Bergersen LJ, McElhinney DB. Comparison of the investigational device exemption and post-approval trials of the Melody transcatheter pulmonary valve. Catheter Cardiovasc Interv 2021; 98:E262-E274. [PMID: 33780150 DOI: 10.1002/ccd.29657] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/03/2020] [Accepted: 03/14/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We compared 5-year outcomes of transcatheter pulmonary valve (TPV) replacement with the Melody TPV in the post-approval study (PAS) and the investigational device exemption (IDE) trial. BACKGROUND As a condition of approval of the Melody TPV after the IDE trial, the Food and Drug Administration required that a PAS be conducted to evaluate outcomes of TPV replacement in a "real-world" environment. The 5-year outcomes of the PAS have not been published, and the IDE and PAS trials have not been compared. METHODS The cohorts comprised all patients catheterized and implanted at 5 IDE sites and 10 PAS sites. Differences in trial protocols were detailed. Time-related outcomes and valve-related adverse events were compared between the two trials with Kaplan-Meier curves and log-rank testing. RESULTS 167 patients (median age, 19 years) were catheterized and 150 underwent TPV replacement in the IDE trial; 121 were catheterized (median age, 17 years) and 100 implanted in the PAS. Freedom from hemodynamic dysfunction (p = .61) or any reintervention (p = .74) over time did not differ between trials. Freedom from stent fracture (p = .003) and transcatheter reintervention (p = .010) were longer in PAS, whereas freedom from explant (p = .020) and TPV endocarditis (p = .007) were shorter. Clinically important adverse events (AEs) were reported in 14% of PAS and 7.2% of IDE patients (p = .056); the incidence of any particular event was low in both. CONCLUSIONS Hemodynamic and time-related outcomes in the PAS and IDE trials were generally similar, confirming the effectiveness of the Melody TPV with real-world providers. There were few significant complications and limited power to identify important differences in AEs. The lack of major differences in outcomes between the two studies questions the usefulness of mandated costly post-approval studies as part of the regulatory process for Class III medical devices.
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Affiliation(s)
- Jacqueline Kreutzer
- Division of Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aimee K Armstrong
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jonathan J Rome
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Thomas M Zellers
- Division of Cardiology, Department of Pediatrics, University of Texas Southwestern and the Heart Center at Children's Health, Dallas, Texas, USA
| | - David T Balzer
- Division of Pediatric Cardiology, Washington University School of Medicine/Saint Louis Children's Hospital, St. Louis, Missouri, USA
| | - Jeffrey D Zampi
- Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Alexander J Javois
- Advocate Children's Hospital, Section of Pediatric Cardiology, Advocate Children's Hospital, University of Illinois Hospital, Chicago, Illinois, USA
| | - Daniel R Turner
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Robert G Gray
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah, USA
| | - John W Moore
- Department of Pediatric Cardiology, Rady Children's Hospital, UC San Diego, San Diego, California, USA
| | - Shicheng Weng
- Department of Biostatistics, Medtronic, Framingham, Massachusetts, USA
| | - Thomas K Jones
- Department of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Danyal M Khan
- The Heart Program, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Julie A Vincent
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York, USA
| | - William E Hellenbrand
- Department of Pediatrics (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - John P Cheatham
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lisa J Bergersen
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California, USA
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6
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Romanowicz J, Guerrelli D, Dhari Z, Mulvany C, Reilly M, Swift L, Vasandani N, Ramadan M, Leatherbury L, Ishibashi N, Posnack NG. Chronic perinatal hypoxia delays cardiac maturation in a mouse model for cyanotic congenital heart disease. Am J Physiol Heart Circ Physiol 2021; 320:H1873-H1886. [PMID: 33739154 DOI: 10.1152/ajpheart.00870.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Compared with acyanotic congenital heart disease (CHD), cyanotic CHD has an increased risk of lifelong mortality and morbidity. These adverse outcomes may be attributed to delayed cardiomyocyte maturation, since the transition from a hypoxic fetal milieu to oxygen-rich postnatal environment is disrupted. We established a rodent model to replicate hypoxic myocardial conditions spanning perinatal development, and tested the hypothesis that chronic hypoxia impairs cardiac development. Pregnant mice were housed in hypoxia beginning at embryonic day 16. Pups stayed in hypoxia until postnatal day (P)8 when cardiac development is nearly complete. Global gene expression was quantified at P8 and at P30, after recovering in normoxia. Phenotypic testing included electrocardiogram, echocardiogram, and ex vivo electrophysiology study. Hypoxic P8 animals were 47% smaller than controls with preserved heart size. Gene expression was grossly altered by hypoxia at P8 (1,427 genes affected), but normalized after recovery (P30). Electrocardiograms revealed bradycardia and slowed conduction velocity in hypoxic animals at P8, with noticeable resolution after recovery (P30). Notable differences that persisted after recovery (P30) included a 65% prolongation in ventricular effective refractory period, sinus node dysfunction, 23% reduction in ejection fraction, and 16% reduction in fractional shortening in animals exposed to hypoxia. We investigated the impact of chronic hypoxia on the developing heart. Perinatal hypoxia was associated with changes in gene expression and cardiac function. Persistent changes to the electrophysiological substrate and contractile function warrant further investigation and may contribute to adverse outcomes observed in the cyanotic CHD population.NEW & NOTEWORTHY We utilized a new mouse model of chronic perinatal hypoxia to simulate the hypoxic myocardial conditions present in cyanotic congenital heart disease. Hypoxia caused numerous abnormalities in cardiomyocyte gene expression, the electrophysiologic substrate of the heart, and contractile function. Taken together, alterations observed in the neonatal period suggest delayed cardiac development immediately following hypoxia.
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Affiliation(s)
- Jennifer Romanowicz
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia
| | - Devon Guerrelli
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia.,Department of Biomedical Engineering, George Washington University, Washington, District of Columbia
| | - Zaenab Dhari
- Center for Neuroscience Research, Children's National Research Institute, Washington, District of Columbia
| | - Colm Mulvany
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Marissa Reilly
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Luther Swift
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Nimisha Vasandani
- Center for Neuroscience Research, Children's National Research Institute, Washington, District of Columbia
| | - Manelle Ramadan
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Linda Leatherbury
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia
| | - Nobuyuki Ishibashi
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia.,Center for Neuroscience Research, Children's National Research Institute, Washington, District of Columbia.,Department of Pediatrics, George Washington University, Washington, District of Columbia.,Department of Pharmacology & Physiology, George Washington University, Washington, District of Columbia
| | - Nikki Gillum Posnack
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia.,Department of Pediatrics, George Washington University, Washington, District of Columbia.,Department of Pharmacology & Physiology, George Washington University, Washington, District of Columbia
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7
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Samuels-Reid JH, Cope JU. Medical devices and the pediatric population - a head-to-toe approach. Expert Rev Med Devices 2019; 16:647-652. [PMID: 31195845 DOI: 10.1080/17434440.2019.1629285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: This review uses a head-to-toe approach, a standardized approach similar to the format used by clinicians during the physical examination, to highlight important differences between children, adolescents and adults. The assessment of a pediatric patient is significantly different from an adult and the heterogeneity of the pediatric population requires knowledge of the inter- and intra-subpopulation differences in growth and development for all organ systems. Areas covered: A search of the English medical literature (PubMed and EMBASE) resulted in identification and review of articles that reported medical device use in the pediatric population based on specific organ systems. The review highlights unique considerations for the pediatric population with respect to growth and development as well as important physiologic and maturational differences between children and adults pertaining to the use of medical devices. Expert opinion: Children have unique medical device needs; adult devices are often adapted or configured to address these unmet needs. It is important that clinicians, and those who manufacture and design medical devices for the pediatric population, have a heightened awareness of the varied pediatric subpopulations (neonates to adolescents) with respect to growth and development, and the adjustments needed to ensure safe and effective use of devices for their unique needs.
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Affiliation(s)
- Joy H Samuels-Reid
- a Division of Anesthesiology, General Hospital, Respiratory, Infection Control and Dental Devices, Office of Device Evaluation, Center for Devices & Radiological Health, Food and Drug Administration , Silver Spring , MD , USA
| | - Judith U Cope
- b Department of Health and Human Services, Office of Pediatric Therapeutics, Office of Special Medical Programs, Office of the Commissioner, Food and Drug Administration , Silver Spring , MD , USA
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8
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Walson PD. From Research to the Bedside: Challenges for Pediatric Academic Researchers. Curr Ther Res Clin Exp 2018; 90:123-127. [PMID: 31388367 PMCID: PMC6677781 DOI: 10.1016/j.curtheres.2018.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 12/14/2018] [Accepted: 12/20/2018] [Indexed: 11/14/2022] Open
Abstract
Public–private collaboration and funding has produced some successful pediatric drug development. Academic pediatricians still face many barriers that limit successful pediatric drug and device development.
Background Although improving, development of drugs and devices for children is still less effective than for adults. Pediatric academicians play an important role in the bench-to-bedside research process, but much remains to be done to improve their contributions. Objective To provide a non-comprehensive review of selected literature based on my own personal experience as a U.S. based academic researcher who has spent over 4 decades doing pediatric drug and device development. Methods This commentary presents a summary of a talk given at a recent pediatric drug development conference. The observations and conclusions reached were based on the author's (largely US) experience and review of past history, the role of academicians in this process, some successful models of public–private collaboration, available funding, and barriers that remain to be overcome. Results Pediatric-specific legislation and more available funding have increased participation from and successes of US academicians in the pediatric drug and device development process. Incentive based public–private collaborations have been particularly successful. However, academicians still face both attitude and practical barriers to success. Conclusions Changes are needed if academicians are to maximize their involvement in pediatric drug and device development.
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Affiliation(s)
- Philip D Walson
- Department of Clinical Pharmacology, University Medical Center, Göttingen, Germany
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9
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Aziz PF, Berger S, Kowey P, Krucoff M, Lopez-Anderson M, Michelson E, Molossi S, Morrow V, Rodriguez I, Saarel TE, Strnadova C, Vetter V, Wright TJ, Idriss SF. The Second Annual Think Tank on Prevention of Sudden Cardiac Death in the Young: Developing a rational, reliable, and sustainable national health care resource. A report from the Cardiac Safety Research Consortium. Am Heart J 2018; 202:104-108. [PMID: 29920452 DOI: 10.1016/j.ahj.2018.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 11/19/2022]
Abstract
Sudden cardiac death in the young (SCDY) spans gender, race, ethnicity, and socioeconomic class. The loss of any pediatric patient is a matter of national and international public health concern, and focused efforts should be aimed at preventing these burdensome tragedies. Prepared by members of the Cardiac Safety Research Consortium, this White Paper summarizes and reports the dialogue at the second Think Tank related to the issues and the proposed solutions for the development of a national resource for screening and prevention of SCDY. This Think Tank, sponsored by the Cardiac Safety Research Consortium and the United States Food and Drug Administration, convened on February 18, 2016, in Miami, FL, to identify and resolve the barriers that prevent early identification of patients at risk for SCDY. All potential stakeholders including national and international experts from industry, medicine, academics, engineering, and community advocacy leaders had an opportunity to share ideas and collaborate.
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Affiliation(s)
- Peter F Aziz
- Pediatric Electrophysiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.
| | - Stuart Berger
- The Willis J. Potts Heart Center, Interim Division Head, Cardiology, Vice Chair, Pediatrics-Ann & Robert H. Lurie Children's Hospital of Chicago, Professor of Pediatrics-Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter Kowey
- Lankenau Heart Institute, Wynnewood, PA, 19096, USA, Professor of Medicine and Clinical Pharmacology Jefferson Medical College, Philadelphia, PA, USA
| | - Mitchell Krucoff
- Duke University Medical Center, Director, Cardiovascular Devices Unit, Director, eECG Core Laboratories, Duke Clinical Research Institute, Durham, NC, USA
| | | | - Eric Michelson
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Silvana Molossi
- Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Tess Elizabeth Saarel
- Pediatric Electrophysiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Colette Strnadova
- Health Products and Food Branch-Health Canada, Government of Canada, Ottawa, Ontario, Canada
| | - Victoria Vetter
- Youth Heart Watch, Professor of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Theressa J Wright
- GPS Cardiology, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN
| | - Salim F Idriss
- Pediatric Cardiology, Pediatric Electrophysiology, Duke Children's Pediatric & Congenital Heart Center, Durham, NC, USA
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10
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Idriss SF, Berger S, Harmon KG, Kindman A, Kleiman R, Lopez-Anderson M, Molossi S, Saarel TE, Strnadova C, Todaro T, Shinagawa K, Morrow V, Krucoff M, Vetter V, Wright TJ. Prevention of sudden cardiac death in the young: Developing a rational, reliable, and sustainable national health care resource. A report from the Cardiac Safety Research Consortium. Am Heart J 2017; 190:123-131. [PMID: 28760206 DOI: 10.1016/j.ahj.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 11/28/2022]
Abstract
This White Paper, prepared by members of the Cardiac Safety Research Consortium, discusses important issues regarding sudden cardiac death in the young (SCDY), a problem that does not discriminate by gender, race, ethnicity, education, socioeconomic level, or athletic status. The occurrence of SCDY has devastating impact on families and communities. Sudden cardiac death in the young is a matter of national and international public health, and its prevention has generated deep interest from multiple stakeholders, including families who have lost children, advocacy groups, academicians, regulators, and the medical industry. To promote scientific and clinical discussion of SCDY prevention and to germinate future initiatives to move this field forward, a Cardiac Safety Research Consortium-sponsored Think Tank was held on February 21, 2015 at the US Food and Drug Administration's White Oak facilities, Silver Spring, MD. The ultimate goal of the Think Tank was to spark initiatives that lead to the development of a rational, reliable, and sustainable national health care resource focused on SCDY prevention. This article provides a detailed summary of discussions at the Think Tank and descriptions of related multistakeholder initiatives now underway: it does not represent regulatory guidance.
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Affiliation(s)
- Salim F Idriss
- Division of Cardiology, Department of Pediatrics, Duke University Medical Center Durham, NC
| | - Stuart Berger
- Division of Pediatric Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kimberly G Harmon
- Departments of Family Medicine and Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | | | | | | | - Silvana Molossi
- Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Colette Strnadova
- Health Products and Food Branch-Health Canada, Government of Canada, Ontario, Canada
| | | | | | | | - Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Victoria Vetter
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Theressa J Wright
- GPS Cardiology, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN
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11
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Hatfield LA, Baugh CM, Azzone V, Normand SLT. Regulator Loss Functions and Hierarchical Modeling for Safety Decision Making. Med Decis Making 2017; 37:512-522. [PMID: 28112994 DOI: 10.1177/0272989x16686767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Regulators must act to protect the public when evidence indicates safety problems with medical devices. This requires complex tradeoffs among risks and benefits, which conventional safety surveillance methods do not incorporate. OBJECTIVE To combine explicit regulator loss functions with statistical evidence on medical device safety signals to improve decision making. METHODS In the Hospital Cost and Utilization Project National Inpatient Sample, we select pediatric inpatient admissions and identify adverse medical device events (AMDEs). We fit hierarchical Bayesian models to the annual hospital-level AMDE rates, accounting for patient and hospital characteristics. These models produce expected AMDE rates (a safety target), against which we compare the observed rates in a test year to compute a safety signal. We specify a set of loss functions that quantify the costs and benefits of each action as a function of the safety signal. We integrate the loss functions over the posterior distribution of the safety signal to obtain the posterior (Bayes) risk; the preferred action has the smallest Bayes risk. Using simulation and an analysis of AMDE data, we compare our minimum-risk decisions to a conventional Z score approach for classifying safety signals. RESULTS The 2 rules produced different actions for nearly half of hospitals (45%). In the simulation, decisions that minimize Bayes risk outperform Z score-based decisions, even when the loss functions or hierarchical models are misspecified. LIMITATIONS Our method is sensitive to the choice of loss functions; eliciting quantitative inputs to the loss functions from regulators is challenging. CONCLUSIONS A decision-theoretic approach to acting on safety signals is potentially promising but requires careful specification of loss functions in consultation with subject matter experts.
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Affiliation(s)
- Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA (LAH, VA)
| | - Christine M Baugh
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, USA (CMB)
| | - Vanessa Azzone
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA (LAH, VA)
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School and Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA (S-LTN)
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12
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Turner JR, Kowey PR, Rodriguez I, Cabell CH, Gintant G, Green CL, Kunz BL, Mortara J, Sager PT, Stockbridge N, Wright TJ, Finkle J, Krucoff MW. The Cardiac Safety Research Consortium enters its second decade: An invitation to participate. Am Heart J 2016; 177:96-101. [PMID: 27297854 DOI: 10.1016/j.ahj.2016.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/20/2016] [Indexed: 01/06/2023]
Abstract
The Cardiac Safety Research Consortium (CSRC), a transparent, public-private partnership established in 2005 as a Critical Path Program and formalized in 2006 under a Memorandum of Understanding between the United States Food and Drug Administration and Duke University, is entering its second decade. Our continuing goal is to advance paradigms for more efficient regulatory science related to the cardiovascular safety of new therapeutics, both in the United States and globally, particularly where such safety questions add burden to innovative research and development. Operationally, CSRC brings together a broad base of stakeholders from academia, industry, and government agencies in a collaborative forum focused on identifying barriers and then creating novel solutions through shared data, expertise, and collaborative research. This white paper provides a brief overview of the Consortium's activities in its first decade and a context for some of our current activities and future directions. The growth and success of the CSRC have been primarily driven by members' active participation and the development of goodwill and trust throughout our membership, which have facilitated novel collaborations across traditionally competitive or contentious stakeholder boundaries. The continued expansion of our base of participating academicians, industry experts, and regulators will define the Consortium's success in our second decade. It is our hope that sharing our endeavors to date will stimulate additional participation in the CSRC and also provide a model for other groups starting to develop similar collaborative forums.
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Affiliation(s)
| | - Peter R Kowey
- Lankenau Institute for Medical Research & Thomas Jefferson University, PA
| | | | | | | | - Cynthia L Green
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC
| | | | | | | | | | | | | | - Mitchell W Krucoff
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC
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13
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Smania G, Baiardi P, Ceci A, Magni P, Cella M. Model-Based Assessment of Alternative Study Designs in Pediatric Trials. Part I: Frequentist Approaches. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 5:305-12. [PMID: 27300083 PMCID: PMC5131885 DOI: 10.1002/psp4.12083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 03/25/2016] [Accepted: 04/18/2016] [Indexed: 11/10/2022]
Abstract
Alternative designs can increase the feasibility of pediatric trials when compared to classical parallel designs (PaD). In this work we present a model-based approach based on clinical trial simulations for the comparison of PaD with the alternative sequential, crossover, and randomized withdrawal (RWD) designs. Study designs were evaluated in terms of: type I and II errors, sample size per arm (SS), trial duration (TD), treatment exposures, and parameter estimate precision (EP). The crossover requires the lowest SS and TD, although it implies higher placebo and no treatment exposures. RWD maximizes exposure to active treatment while minimizing that to placebo, but requires the largest SS. SS of sequential designs can sometimes be smaller than the crossover one, although with poorer EP. This pharmacometric framework allows a multiscale comparison of alternative study designs that can be used for design selection in future pediatric trials.
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Affiliation(s)
- G Smania
- Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy.,Dipartimento di Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - P Baiardi
- Direzione Scientifica Centrale, Fondazione Salvatore Maugeri, IRCCS, Pavia, Italy
| | - A Ceci
- Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy
| | - P Magni
- Dipartimento di Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - M Cella
- Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy.,Department of Clinical Pharmacology, Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
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14
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Felson DT, Redmond AC, Chapman GJ, Smith TO, Hamilton DF, Jones RK, Holt CA, Callaghan MJ, Mason DJ, Conaghan PG. Recommendations for the conduct of efficacy trials of treatment devices for osteoarthritis: a report from a working group of the Arthritis Research UK Osteoarthritis and Crystal Diseases Clinical Studies Group. Rheumatology (Oxford) 2015; 55:320-6. [PMID: 26361882 DOI: 10.1093/rheumatology/kev328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE There are unique challenges to designing and carrying out high-quality trials testing therapeutic devices in OA and other rheumatic diseases. Such challenges include determining the mechanisms of action of the device and the appropriate sham. Design of device trials is more challenging than that of placebo-controlled drug trials. Our aim was to develop recommendations for designing device trials. METHODS An Arthritis Research UK study group comprised of 30 rheumatologists, physiotherapists, podiatrists, engineers, orthopaedists, trialists and patients, including many who have carried out device trials, met and (using a Delphi-styled approach) came to consensus on recommendations for device trials. RESULTS Challenges unique to device trials include defining the mechanism of action of the device and, therefore, the appropriate sham that provides a placebo effect without duplicating the action of the active device. Should there be no clear-cut mechanism of action, a three-arm trial including a no-treatment arm and one with presumed sham action was recommended. For individualized devices, generalizable indications and standardization of the devices are needed so that treatments can be generalized. CONCLUSION A consensus set of recommendations for device trials was developed, providing a basis for improved trial design, and hopefully improvement in the number of effective therapeutic devices for rheumatic diseases.
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Affiliation(s)
- David T Felson
- Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, UK, Clinical Epidemiology Unit, School of Medicine, Boston University, Boston, USA,
| | - Anthony C Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds
| | - Graham J Chapman
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds
| | - Toby O Smith
- School of Health Sciences, University of East Anglia, Norwich
| | | | - Richard K Jones
- School of Health Sciences, University of Salford, Lancashire
| | - Cathy A Holt
- School of Engineering, Cardiff University and Arthritis Research UK Biomechanics and Bioengineering Centre and
| | - Michael J Callaghan
- Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, UK
| | - Deborah J Mason
- Cardiff School of Biosciences, Cardiff University, Cardiff, UK
| | | | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds
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15
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McElhinney DB. Will there ever be a Food and Drug Administration-approved device for transcatheter paravalvular leak closure? Circ Cardiovasc Interv 2014; 7:2-5. [PMID: 24550528 DOI: 10.1161/circinterventions.114.001286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Doff B McElhinney
- From the Departments of Pediatrics, Medicine, and Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY
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16
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The Future of Population-Based Postmarket Drug Risk Assessment: A Regulator’s Perspective. Clin Pharmacol Ther 2013; 94:349-58. [DOI: 10.1038/clpt.2013.118] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 05/29/2013] [Indexed: 01/03/2023]
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17
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Affiliation(s)
- Antonio Francesco Corno
- King Fahad Medical City, Cardiovascular Surgery/Pediatric Cardiac Surgery Riyadh, Saudi Arabia
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