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Dienstman J, Stachelek SJ, Krieger AM, Eskandanian K, Espinoza JC, Harrison MR, Koh CJ, Peiris V, Torjusen E, Levy RJ. Pediatric Device Clinical Trials Activity: 1999-2022. Pediatrics 2024:e2023063466. [PMID: 38953121 DOI: 10.1542/peds.2023-063466] [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] [Received: 08/03/2023] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVES This study assessed the state of pediatric medical device (PMD) development by comparing PMD clinical trials to pediatric trials evaluating drugs and biologics, from 1999 to 2022. METHODS The site https://www.clinicaltrials.gov was used to identify and quantify both PMD clinical trials and pediatric trials for drugs and biologics. Clinical specialty was also assessed. The institutions included were the 7 children's hospitals primarily affiliated with the Food and Drug Administration (FDA) Pediatric Device Consortia (PDC) grant program between 2018 and 2023. For a national comparison, an additional search assessed PMD trials across all US medical institutions. RESULTS A total of 243 PMD clinical trials were identified at the FDA-PDC institutions on the basis of the year of initiation; the average number of PMD trials initiated per year per institution was 1.5 from 1999 to 2022. However, PMD trials significantly increased during the period 2014 to 2022 compared with 1999 to 2013 (P < .001); the rate of initiation of drug and biologic pediatric trials demonstrated no significant differences between these time periods. A national survey of all institutions initiating PMD trials, and drugs and biologics trials, identified 1885 PMD trials out of a total 12 943. A comparable trend was noted in the national survey with initiation of PMD trials increasing significantly from 2014 to 2022 (P < .001), compared with 1999 to 2013, whereas the rate of initiation of drug and biologic trials during these periods did not demonstrate a significant change. CONCLUSIONS Although pediatric clinical trial initiation for drugs and biologics remained stable from 1999 to 2022, the rate of new PMD trials significantly increased during the period 2014 to 2022 at FDA-PDC institutions and nationally.
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Affiliation(s)
- Joshua Dienstman
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stanley J Stachelek
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Abba M Krieger
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kolaleh Eskandanian
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia
| | - Juan C Espinoza
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael R Harrison
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Vasum Peiris
- Pediatrics and Special Populations, Center for Devices and Radiological Health; and
| | - Erika Torjusen
- Office of Orphan Products Development, Office of the Commissioner, Food and Drug Administration, Silver Spring, Maryland
| | - Robert J Levy
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Kysh L, Zapotoczny G, Manzanete L, Carey M, Shah P, Joseph F, Kempf H, Sikder AT, Finkel J, Thekkedath U, Toman K, Koh CJ, Eskandanian K, Espinoza J. Barriers to and facilitators of paediatric medical device innovation: a scoping review protocol. BMJ Open 2024; 14:e081541. [PMID: 38839390 PMCID: PMC11163634 DOI: 10.1136/bmjopen-2023-081541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/14/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION The development of paediatric medical devices continues to lag adult medical devices and contributes to issues of inequity, safety, quality and patient outcomes. New legislation and funding mechanisms have been introduced over the past two decades, but the gap remains. Clinical trials have been identified as a pain point, but components of effective clinical research infrastructure are poorly understood. As part of a multimodal research strategy, the Pediatric Device Consortia (PDC) will conduct a scoping review to better understand infrastructural barriers to and facilitators of paediatric medical device clinical research identified in the health sciences literature. METHODS AND ANALYSIS The following databases will be included for this review: Medline, Embase, Cochrane CENTRAL, Web of Science and IEEE Xplore. Additional grey literature will be sought out through Google Scholar and reviewing the citations of included studies. Included studies will discuss medical devices according to the U.S. Food and Drug Administration classification, focus on the paediatric population (ages 0-21 years) and involve human premarket or postmarket research. All study types that were published in 2007-present in English, Spanish, French or Italian will be included. Using Covidence web-based software, two independent reviewers will screen the resulting titles, abstracts and the full text of potential studies. Conflicts will be resolved by the primary investigator during both phases. REDCap will be used for quantitative and qualitative data charting, generating data tables and narrative synthesis. ETHICS AND DISSEMINATION This research did not require research ethics board consideration as it does not involve human participants and all data will be collected from published literature. We will share our findings through peer-reviewed manuscripts, clinical and research conference presentations and professional networks available to the PDC. STUDY REGISTRATION Open Science Framework (https://osf.io/k72bn).
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Affiliation(s)
- Lynn Kysh
- Innovation Studio, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Grzegorz Zapotoczny
- Stanley Manne Children's Research Institute, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- West Coast Consortium for Technology & Innovation in Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lisa Manzanete
- Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Megan Carey
- West Coast Consortium for Technology & Innovation in Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Payal Shah
- West Coast Consortium for Technology & Innovation in Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Francesca Joseph
- Division of Pediatrics, Children's National Hospital, Washington, DC, USA
- National Capital Consortium for Pediatric Device Innovation, Children's National Hospital, Washington, DC, USA
| | - Haley Kempf
- Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Abu Taher Sikder
- Innovation Studio, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Julia Finkel
- National Capital Consortium for Pediatric Device Innovation, Children's National Hospital, Washington, DC, USA
- Division of Anesthesiology, Children's National Hospital, Washington, DC, USA
| | - Usha Thekkedath
- Department of Surgery and Bioengineering & Therapeutics Sciences, University of California San Francisco, San Francisco, California, USA
| | - Kara Toman
- Division of Pediatric Urology, Baylor College of Medicine, Houston, Texas, USA
| | - Chester J Koh
- Division of Pediatric Urology, Texas Children's Hospital, Houston, Texas, USA
| | - Kolaleh Eskandanian
- National Capital Consortium for Pediatric Device Innovation, Children's National Hospital, Washington, DC, USA
| | - Juan Espinoza
- Stanley Manne Children's Research Institute, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- West Coast Consortium for Technology & Innovation in Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
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Dubin J, Sardesai K, Grote C, Tougas C, Branche K, Otsuka N. Pediatric Device Innovation: An Analysis of Food and Drug Administration Authorizations Over Time. J Bone Joint Surg Am 2024:00004623-990000000-01123. [PMID: 38838107 DOI: 10.2106/jbjs.23.01211] [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] [Indexed: 06/07/2024]
Abstract
BACKGROUND Despite a tremendous increase in the number of orthopaedic devices authorized by the U.S. Food and Drug Administration (FDA), novel devices designed specifically for the pediatric population remain sparse. Surgeons frequently repurpose adult implants for "off-label" use in pediatric patients, with both legal and technical ramifications. This study seeks to objectively quantify and characterize the nature of pediatric device innovation over time. METHODS The FDA employs 4 pathways for assessing safety and effectiveness of novel devices prior to authorization. Perceived device risk and novelty determine the pathway. Orthopaedic devices were identified from the FDA's online database. All devices approved since inception via the Humanitarian Device Exemption, Pre-Market Approval, and De Novo regulatory pathways were included and grouped as "highly innovative." Because of their number and the rapidity of their development, the evaluation of 510(k) devices was limited to those cleared from January 1, 2018, to December 31, 2022. Such 510(k) devices make up ∼97% of devices and by definition are less risky and less novel. Approval statements were assessed for pediatric indications within the approved labeling. As a secondary analysis, the impact of company size on developing a product with a pediatric indication was analyzed. RESULTS Of the 1,925 devices cleared via the 510(k) pathway, 9 (0.5%) were designed exclusively for pediatrics and 160 (8.3%) included pediatric indications. Five of the 9 pediatrics-only devices were for spine and 4 were for trauma indications. Of the 97 highly innovative devices, only 2 (2%) were exclusively pediatric and another 2 (2%) included pediatric indications. The 2 pediatrics-only devices were for the spine. Large and medium-sized companies were 1.9 times and 1.6 times more likely to bring to market a device with pediatric indications than a small company, respectively. CONCLUSIONS Innovation for pediatric orthopaedic devices lags substantially behind that for adult orthopaedic devices. These findings are consistent with clinical experience and the common practice of modifying adult implants for "off-label" use in pediatric patients. Despite long-standing efforts to stimulate innovation for this vulnerable population, our results suggest little progress.
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Affiliation(s)
- Jonathan Dubin
- University of Missouri-Kansas City, Kansas City, Missouri
- University Health Truman Medical Center, Kansas City, Missouri
| | - Krish Sardesai
- University of Missouri-Kansas City, Kansas City, Missouri
| | - Caleb Grote
- University of Missouri-Kansas City, Kansas City, Missouri
- Children's Mercy, Kansas City, Missouri
| | - Caroline Tougas
- University of Missouri-Kansas City, Kansas City, Missouri
- Children's Mercy, Kansas City, Missouri
| | | | - Norman Otsuka
- University of Missouri-Kansas City, Kansas City, Missouri
- Children's Mercy, Kansas City, Missouri
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Pelizzo G, Destro F, Pierucci UM, Costanzo S, Camporesi A, Diotto V, Calcaterra V, Saxena AK. Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures. CHILDREN (BASEL, SWITZERLAND) 2024; 11:679. [PMID: 38929258 PMCID: PMC11201956 DOI: 10.3390/children11060679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/20/2024] [Accepted: 05/26/2024] [Indexed: 06/28/2024]
Abstract
Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.
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Affiliation(s)
- Gloria Pelizzo
- Department of Biomedical and Clinical Science, University of Milan, 20157 Milan, Italy;
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Francesca Destro
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Ugo Maria Pierucci
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Sara Costanzo
- Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (U.M.P.); (S.C.)
| | - Anna Camporesi
- Pediatric Anesthesiology and Intensive Care Unit, Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (A.C.); (V.D.)
| | - Veronica Diotto
- Pediatric Anesthesiology and Intensive Care Unit, Department of Pediatric Surgery, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy; (A.C.); (V.D.)
| | - Valeria Calcaterra
- Department of Pediatrics, “V. Buzzi” Children’s Hospital, 20154 Milan, Italy;
| | - Amulya K. Saxena
- Department of Pediatric Surgery, Chelsea Children’s Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, London SW10 9NH, UK;
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Mascarenhas E, Miguel LS, Oliveira MD, Fernandes RM. Economic evaluations of medical devices in paediatrics: a systematic review and a quality appraisal of the literature. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:33. [PMID: 38678250 PMCID: PMC11056067 DOI: 10.1186/s12962-024-00537-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/21/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Although economic evaluations (EEs) have been increasingly applied to medical devices, little discussion has been conducted on how the different health realities of specific populations may impact the application of methods and the ensuing results. This is particularly relevant for pediatric populations, as most EEs on devices are conducted in adults, with specific aspects related to the uniqueness of child health often being overlooked. This study provides a review of the published EEs on devices used in paediatrics, assessing the quality of reporting, and summarising methodological challenges. METHODS A systematic literature search was performed to identify peer-reviewed publications on the economic value of devices used in paediatrics in the form of full EEs (comparing both costs and consequences of two or more devices). After the removal of duplicates, article titles and abstracts were screened. The remaining full-text articles were retrieved and assessed for inclusion. In-vitro diagnostic devices were not considered in this review. Study descriptive and methodological characteristics were extracted using a structured template. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist was used to assess the quality of reporting. A narrative synthesis of the results was conducted followed by a critical discussion on the main challenges found in the literature. RESULTS 39 full EEs were eligible for review. Most studies were conducted in high-income countries (67%) and focused on high-risk therapeutic devices (72%). Studies comprised 25 cost-utility analyses, 13 cost-effectiveness analyses and 1 cost-benefit analysis. Most of the studies considered a lifetime horizon (41%) and a health system perspective (36%). Compliance with the CHEERS 2022 items varied among the studies. CONCLUSIONS Despite the scant body of evidence on EEs focusing on devices in paediatrics results highlight the need to improve the quality of reporting and advance methods that can explicitly incorporate the multiple impacts related to the use of devices with distinct characteristics, as well as consider specific child health realities. The design of innovative participatory approaches and instruments for measuring outcomes meaningful to children and their families should be sought in future research.
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Affiliation(s)
- Edgar Mascarenhas
- Centro de Estudos de Gestão do Instituto Superior Técnico (CEG-IST), Instituto Superior Técnico, Universidade de Lisboa, Avenida Rovisco Pais, 1049-001, Lisboa, Portugal.
| | - Luís Silva Miguel
- Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Mónica D Oliveira
- Centro de Estudos de Gestão do Instituto Superior Técnico (CEG-IST), Instituto Superior Técnico, Universidade de Lisboa, Avenida Rovisco Pais, 1049-001, Lisboa, Portugal
- iBB- Institute for Bioengineering and Biosciences and i4HB- Associate Laboratory Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal
| | - Ricardo M Fernandes
- Laboratório de Farmacologia e Terapêutica, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Departmento de Pediatria, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
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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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Taha S, Simpson RB, Sharkey D. The critical role of technologies in neonatal care. Early Hum Dev 2023; 187:105898. [PMID: 37944264 DOI: 10.1016/j.earlhumdev.2023.105898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
Neonatal care has made significant advances in the last few decades. As a result, mortality and morbidity in high-risk infants, such as extremely preterm infants or those infants with birth-related brain injury, has reduced significantly. Many of these advances have been facilitated or delivered through development of medical technologies allowing clinical teams to be better supported with the care they deliver or provide new therapies and diagnostics to improve management. The delivery of neonatal intensive care requires the provision of medical technologies that are easy to use, reliable, accurate and ideally developed for the unique needs of the newborn population. Many technologies have been developed and commercialised following adult trials without ever being studied in neonatal patients despite the unique characteristics of this population. Increasingly, funders and industry are recognising this major challenge which has resulted in initiatives to develop new ideas from concept through to clinical care. This review explores some of the key medical technologies used in neonatal care and the evidence to support their adoption to improve outcomes. A number of devices have yet to realise their full potential and will require further development to optimise and find their ideal target population and clinical benefit. Examples of emerging technologies, which may soon become more widely used, are also discussed. As neonatal care relies more on medical technologies, we need to be aware of the impact on care pathways, especially from a human factors approach, the associated costs and subsequent benefits to patients alongside the supporting evidence.
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Affiliation(s)
- Syed Taha
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Rosalind B Simpson
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Don Sharkey
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom.
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Brewster RCL, Wu A, Carroll RW. Open source approaches for pediatric global health technologies. J Med Eng Technol 2023; 47:371-375. [PMID: 38717814 DOI: 10.1080/03091902.2024.2343682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/09/2024] [Indexed: 06/14/2024]
Abstract
Access to medical technologies is a critical component of universal access to care; however, the advancement of technologies for children has historically lagged behind those for adults. The small market size, anatomic and physiologic variability, and legal and ethical implications pose unique barriers to developing and commercialising paediatric biomedical innovations. These challenges are magnified in low-resource settings (LRS), which often lack appropriate regulatory oversight, support for service contracts, and supply chain capacity. The COVID-19 pandemic exposed shortcomings in the traditional industry model for medical technologies, while also catalysing open-source approaches to technology development and dissemination. Open-source pathways - where products are freely licenced to be distributed and modified - addressed key shortages in critical equipment. Relatedly, we argue that open-source approaches can accelerate paediatric global health technology development. Open-source approaches can be tailored to clinical challenges independent of economic factors, embrace low-cost manufacturing techniques, and can be highly customisable. Furthermore, diverse stakeholders, including families and patients, are empowered to participate in collaborative communities of practice. How to regulate the development, manufacture, and distribution of open-source technologies remains an ongoing area of exploration. The need for democratised innovation must be carefully balanced against the imperatives of safety and quality for paediatric-specific solutions. This can be achieved, in part, through close coordination between national regulatory agencies and decentralised networks where products can be peer-reviewed and tested. Altogether, there is significant potential for open source to advance more equitable and sustainable medical innovations for all children.
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Affiliation(s)
- Ryan C L Brewster
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Andrew Wu
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Ryan W Carroll
- Division of Critical Care Medicine, Massachusetts General Hospital for Children, Boston, MA, USA
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Speer EM, Lee LK, Bourgeois FT, Gitterman D, Hay WW, Davis JM, Javier JR. The state and future of pediatric research-an introductory overview : The state and future of pediatric research series. Pediatr Res 2023:10.1038/s41390-022-02439-4. [PMID: 36694026 PMCID: PMC9873210 DOI: 10.1038/s41390-022-02439-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/23/2022] [Indexed: 01/26/2023]
Abstract
IMPACT This is an introduction to an article series devoted to the current state and future of pediatric research. The role of public-private partnerships, influencing factors, challenges, and recent trends in pediatric research are described, with emphasis on funding, drug and device development, physician-scientist training, and diversity. Potential solutions and advocacy opportunities are discussed.
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Affiliation(s)
- Esther M Speer
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.
| | - Lois K Lee
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Florence T Bourgeois
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA, USA
| | - Daniel Gitterman
- Public Policy, University of North Caroline, Chapel Hill, NC, USA
| | | | - Jonathan M Davis
- Department of Pediatrics and the Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
| | - Joyce R Javier
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Pathak K, Narang C, Hwang TJ, Espinoza JC, Bourgeois FT. High-risk Therapeutic Devices Approved by the US Food and Drug Administration for Use in Children and Adolescents From 2016 to 2021. JAMA Pediatr 2023; 177:98-100. [PMID: 36342722 PMCID: PMC9641589 DOI: 10.1001/jamapediatrics.2022.4131] [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] [Indexed: 11/09/2022]
Abstract
This cohort study examines the characteristics of high-risk therapeutic devices approved by the US Food and Drug Administration for use in children and adolescents between 2016 and 2021.
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Affiliation(s)
| | - Claire Narang
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
| | - Thomas J. Hwang
- Division of Urological Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Juan C. Espinoza
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
| | - Florence T. Bourgeois
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Drummond D, Coulet A. Technical, Ethical, Legal, and Societal Challenges With Digital Twin Systems for the Management of Chronic Diseases in Children and Young People. J Med Internet Res 2022; 24:e39698. [DOI: 10.2196/39698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/11/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
Advances in digital medicine now make it possible to use digital twin systems (DTS), which combine (1) extensive patient monitoring through the use of multiple sensors and (2) personalized adaptation of patient care through the use of software. After the artificial pancreas system already operational in children with type 1 diabetes, new DTS could be developed for real-time monitoring and management of children with chronic diseases. Just as providing care for children is a specific discipline—pediatrics—because of their particular characteristics and needs, providing digital care for children also presents particular challenges. This article reviews the technical challenges, mainly related to the problem of data collection in children; the ethical challenges, including the need to preserve the child's place in their care when using DTS; the legal challenges and the dual need to guarantee the safety of DTS for children and to ensure their access to DTS; and the societal challenges, including the needs to maintain human contact and trust between the child and the pediatrician and to limit DTS to specific uses to avoid contributing to a surveillance society and, at another level, to climate change.
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Espinoza J, Shah P, Nagendra G, Bar-Cohen Y, Richmond F. Pediatric Medical Device Development and Regulation: Current State, Barriers, and Opportunities. Pediatrics 2022; 149:186768. [PMID: 35425971 DOI: 10.1542/peds.2021-053390] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/24/2022] Open
Abstract
Few medical devices are designed and marketed specifically for children. Instead, adult devices are often repurposed and used off-label in pediatrics. The innovation gap between pediatric and adult devices is complex and multifactorial. This review aims to summarize the medical device landscape, describe barriers to pediatric device development, and provide an update on current strategies to help overcome these limitations. Medical devices are regulated by the Food and Drug Administration. They are registered, cleared, or approved on the basis of a 3-tier risk classification system and a differentiated set of regulatory pathways. This includes some for products that receive special designations on the basis of specific aspects that warrant more rapid review and approval. Pediatric devices number only one-quarter of those developed for adults for multiple reasons. Clinically, innovators must adjust their products to address the smaller sizes, growth, and longer duration of use in children. Smaller sample sizes and population heterogeneity also challenge the ability to obtain sufficient safety data for regulatory submissions. Financial concerns stem from lower pediatric reimbursement rates coupled with a lack of nationally standardized coverage. There are a number of promising initiatives, including the Pediatric Device Consortia Program, Early Feasibility Studies, and the new System of Hospitals for Innovation in Pediatrics - Medical Devices. However, the gap will likely not be narrowed without broad cooperation across stakeholders from industry, academia, patient advocacy groups, health care providers, investors, payors, regulators, and Congress.
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Affiliation(s)
- Juan Espinoza
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Payal Shah
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Gautam Nagendra
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Yaniv Bar-Cohen
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Frances Richmond
- Department of Regulatory & Quality Sciences, School of Pharmacy, University of Southern California, Los Angeles, California
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13
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Batey N, Henry C, Garg S, Wagner M, Malhotra A, Valstar M, Smith T, Sharkey D. The newborn delivery room of tomorrow: emerging and future technologies. Pediatr Res 2022:10.1038/s41390-022-01988-y. [PMID: 35241791 DOI: 10.1038/s41390-022-01988-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/10/2022] [Accepted: 02/01/2022] [Indexed: 11/08/2022]
Abstract
Advances in neonatal care have resulted in improved outcomes for high-risk newborns with technologies playing a significant part although many were developed for the neonatal intensive care unit. The care provided in the delivery room (DR) during the first few minutes of life can impact short- and long-term neonatal outcomes. Increasingly, technologies have a critical role to play in the DR particularly with monitoring and information provision. However, the DR is a unique environment and has major challenges around the period of foetal to neonatal transition that need to be overcome when developing new technologies. This review focuses on current DR technologies as well as those just emerging and further over the horizon. We identify what key opinion leaders in DR care think of current technologies, what the important DR measures are to them, and which technologies might be useful in the future. We link these with key technologies including respiratory function monitors, electoral impedance tomography, videolaryngoscopy, augmented reality, video recording, eye tracking, artificial intelligence, and contactless monitoring. Encouraging funders and industry to address the unique technological challenges of newborn care in the DR will allow the continued improvement of outcomes of high-risk infants from the moment of birth. IMPACT: Technological advances for newborn delivery room care require consideration of the unique environment, the variable patient characteristics, and disease states, as well as human factor challenges. Neonatology as a speciality has embraced technology, allowing its rapid progression and improved outcomes for infants, although innovation in the delivery room often lags behind that in the intensive care unit. Investing in new and emerging technologies can support healthcare providers when optimising care and could improve training, safety, and neonatal outcomes.
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Affiliation(s)
- Natalie Batey
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Caroline Henry
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalabh Garg
- Department of Neonatal Medicine, James Cook University Hospital, Middlesbrough, UK
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital and Department of Paediatrics, Monash University, Melbourne, Australia
| | - Michel Valstar
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Thomas Smith
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Nottingham Neonatal Service, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK.
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Fraser AG, Nelissen RGHH, Kjærsgaard-Andersen P, Szymański P, Melvin T, Piscoi P. Improved clinical investigation and evaluation of high-risk medical devices: the rationale and objectives of CORE-MD (Coordinating Research and Evidence for Medical Devices). EFORT Open Rev 2021; 6:839-849. [PMID: 34760284 PMCID: PMC8559562 DOI: 10.1302/2058-5241.6.210081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the European Union (EU), the delivery of health services is a national responsibility but there are concerted actions between member states to protect public health. Approval of pharmaceutical products is the responsibility of the European Medicines Agency, while authorising the placing on the market of medical devices is decentralised to independent ‘conformity assessment’ organisations called notified bodies. The first legal basis for an EU system of evaluating medical devices and approving their market access was the Medical Device Directive, from the 1990s. Uncertainties about clinical evidence requirements, among other reasons, led to the EU Medical Device Regulation (2017/745) that has applied since May 2021. It provides general principles for clinical investigations but few methodological details – which challenges responsible authorities to set appropriate balances between regulation and innovation, pre- and post-market studies, and clinical trials and real-world evidence. Scientific experts should advise on methods and standards for assessing and approving new high-risk devices, and safety, efficacy, and transparency of evidence should be paramount. The European Commission recently awarded a Horizon 2020 grant to a consortium led by the European Society of Cardiology and the European Federation of National Associations of Orthopaedics and Traumatology, that will review methodologies of clinical investigations, advise on study designs, and develop recommendations for aggregating clinical data from registries and other real-world sources. The CORE–MD project (Coordinating Research and Evidence for Medical Devices) will run until March 2024. Here, we describe how it may contribute to the development of regulatory science in Europe. Cite this article: EFORT Open Rev 2021;6:839-849. DOI: 10.1302/2058-5241.6.210081
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Affiliation(s)
- Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Piotr Szymański
- Centre of Postgraduate Medical Education, MSWiA Central Clinical Hospital, Warsaw, Poland
| | - Tom Melvin
- Healthcare Products Regulatory Authority, Earlsfort Terrace, Dublin 2, Ireland
| | - Paul Piscoi
- Health Technology Unit B6, Directorate General for Health (DG SANTE), European Commission, Brussels, Belgium
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Advancing pediatric medical device development via non-dilutive NIH SBIR/STTR grant funding. J Pediatr Surg 2021; 56:2118-2123. [PMID: 33558071 PMCID: PMC9125501 DOI: 10.1016/j.jpedsurg.2021.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION A shortage of medical devices designed for children persists due to the smaller pediatric population and market factors. Furthermore, pediatric device development is challenging due to the limited available funding sources. We describe our experience with pediatric device projects that successfully received federal grant support towards commercializing the devices that can serve as a guide for future innovators. METHODS The developmental pathways of pediatric device projects at a tertiary-care children's hospital that received NIH SBIR/STTR funding between 2016-2019 were reviewed. The clinical problems, designs, specific aims, and development phase were delineated. RESULTS Pediatric faculty successfully secured NIH SBIR/STTR funding for five pediatric devices via qualified small business concerns (SBC's). Three projects were initiated in the capstone engineering design programs and developed further at two affiliated engineering schools, while the other two projects were developed in the faculty members' labs. Four projects received funding via established SBC's, while one was awarded funding via a newly established SBC. CONCLUSION NIH SBIR/STTR grants are an essential source of external non-dilutive funding for pediatric device innovation and especially for academic-initiated projects. This funding can provide needed early-stage support to facilitate commercialization. In addition, these grants can serve as achievable accomplishments for pediatric faculty portfolios toward academic promotion. Our experience shows that it is possible to build a robust innovation ecosystem comprised of academic faculty (clinical/engineering) collaborating with local device development companies while jointly implementing a product development strategy leveraging NIH SBIR/STTR funding for critical translational research phases of pediatric device development.
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16
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Fraser AG, Nelissen RGHH, Kjærsgaard-Andersen P, Szymański P, Melvin T, Piscoi P. Improved clinical investigation and evaluation of high-risk medical devices: the rationale and objectives of CORE-MD (Coordinating Research and Evidence for Medical Devices). EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:249-258. [PMID: 34448829 PMCID: PMC9071523 DOI: 10.1093/ehjqcco/qcab059] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022]
Abstract
In the European Union (EU) the delivery of health services is a national responsibility but there are concerted actions between member states to protect public health. Approval of pharmaceutical products is the responsibility of the European Medicines Agency, while authorising the placing on the market of medical devices is decentralised to independent 'conformity asssessment' organisations called notified bodies. The first legal basis for an EU system of evaluating medical devices and approving their market access was the medical device directives, from the 1990s. Uncertainties about clinical evidence requirements, among other reasons, led to the EU Medical Device Regulation (2017/745) that has applied since May 2021. It provides general principles for clinical investigations but few methodological details ‒ which challenges responsible authorities to set appropriate balances between regulation and innovation, pre- and post-market studies, and clinical trials and real-world evidence. Scientific experts should advise on methods and standards for assessing and approving new high-risk devices, and safety, efficacy, and transparency of evidence should be paramount. The European Commission recently awarded a Horizon 2020 grant to a consortium led by the European Society of Cardiology and the European Federation of National Associations of Orthopaedics and Traumatology, that will review methodologies of clinical investigations, advise on study designs, and develop recommendations for aggregating clinical data from registries and other real-world sources. The CORE‒MD project (Coordination of Research and Evidence for Medical Devices) will run until March 2024; here we describe how it may contribute to the development of regulatory science in Europe.
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Affiliation(s)
- A G Fraser
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
| | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - P Kjærsgaard-Andersen
- Department of Orthopaedics, Vejle Hospital, South Danish University, DK-7100 Vejle, Denmark
| | - P Szymański
- Centre of Postgraduate Medical Education, MSWiA Central Clinical Hospital, ul. Woloska 137, 02-507 Warsaw, Poland
| | - T Melvin
- Healthcare Products Regulatory Authority, Earlsfort Terrace, Dublin 2, Ireland
| | - P Piscoi
- Health Technology Unit B6, Directorate General for Health (DG SANTE), European Commission, Brussels, Belgium
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Lee SJ, Cho L, Klang E, Wall J, Rensi S, Glicksberg BS. Quantification of US Food and Drug Administration Premarket Approval Statements for High-Risk Medical Devices With Pediatric Age Indications. JAMA Netw Open 2021; 4:e2112562. [PMID: 34156454 PMCID: PMC8220494 DOI: 10.1001/jamanetworkopen.2021.12562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Medical device companies submit premarket approval (PMA) statements to the US Food and Drug Administration (FDA) for approval of the highest-risk class of devices. Devices indicated for the pediatric population that use the PMA pathway have not been well characterized or analyzed. OBJECTIVE To identify and characterize high-risk devices with pediatric age indications derived from PMA statements. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study of PMA statements, those statements containing the words indicated or intended for medical devices listed in the FDA PMA database as of February 2020 were retrieved. Age indications were manually annotated in these approval statements via PubAnnotation. Based on the PMA identification from the PMA statements, device metadata including product codes, regulation numbers, advisory panels, and approval dates were queried. MAIN OUTCOMES AND MEASURES The main outcome was discernment of the distribution of devices indicated for the pediatric population (neonate, infant, child, and adolescent). Secondary measures included outlining the clinical specialties, device types, and lag time between the initial approval date and the first date of an approval statement with a pediatric indication for generic device categories. RESULTS A total of 297 documents for 149 unique devices were analyzed. Based on the manual age annotations, 102 devices with a pediatric indication, 10 with a neonate age indication, 32 with an infant age indication, 60 with a child age indication, and 94 with an adolescent age indication were identified. For indications for patients from age 17 to 18 years, the number of devices available nearly doubled from 42 devices to 81 devices. Although more than half of the surveyed devices had a pediatric age indication, many were available only for a limited range of the pediatric population (age 18-21 years). For indications for patients from age 0 to 17 years, the mean (SD) number of clinical specialties at each age was 7.27 (1.4), and 12 clinical specialties were represented from ages 18 to 21 years. CONCLUSIONS AND RELEVANCE In this cross-sectional study on device PMA statements, a gap was identified in both quantity and diversity of high-risk devices indicated for the pediatric population. Because the current scarcity of pediatric devices may limit therapeutic possibilities for children, this study represents a step toward quantifying this scarcity and identifying clinical specialties with the greatest need for pediatric device innovation and may help inform future device development efforts.
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Affiliation(s)
- Samuel J. Lee
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren Cho
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eyal Klang
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Wall
- Department of Surgery, Stanford University, Stanford, California
| | - Stefano Rensi
- School of Medicine, Stanford University, Stanford, California
| | - Benjamin S. Glicksberg
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
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18
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Affiliation(s)
- Juan C Espinoza
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
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19
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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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Humphries T, Kushalnagar P, Mathur G, Napoli DJ, Rathmann C. Global Regulatory Review Needed for Cochlear Implants: A Call for FDA Leadership. Matern Child Health J 2020; 24:1345-1359. [PMID: 32876813 DOI: 10.1007/s10995-020-03002-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Using the United States Food and Drug Administration (FDA) as example, we argue that regulatory agencies worldwide should review their guidance on cochlear implants (CIs). METHODS This is a position paper, thus the methods are strictly argumentation. Here we give the motivation for our recommendation. The FDA's original approval of implantation in prelingually deaf children was granted without full benefit of information on language acquisition, on childcaregiver communication, and on the lived experience of being deaf. The CI clinical trials, accordingly, did not address risks of linguistic deprivation, especially when the caregiver's communication is not fully accessible to the prelingually deaf child. Wide variability in the effectiveness of CIs since initial and updated approval has been indicated but has not led to new guidance. Children need to be exposed frequently and regularly to accessible natural language while their brains are still plastic enough to become fluent in any language. For the youngest infants, who are not yet producing anything that could be called language although they might be producing salient social signals (Goldstein et al. Child Dev 80:636-644, 2009), good comprehension of communication from caregiver to infant is critical to the development of language. Sign languages are accessible natural languages that, because they are visual, allow full immersion for deaf infants, and they supply the necessary support for this comprehension. The main language contributor to health outcomes is this combination of natural visual language and comprehension in communication. Accordingly, in order to prevent possible language deprivation, all prelingually deaf children should be exposed to both sign and spoken languages when their auditory status is detected, with sign language being critical during infancy and early childhood. Additionally, all caregivers should be given support to learn a sign language if it is new to them so that they can comprehend their deaf children's language expressions fully. However, both languages should be made accessible in their own right, not combined in a simultaneous or total communication approach since speaking one language and signing the other at the same time is problematic. RESULTS Again, because this is a position paper, our results are our recommendations. We call for the FDA (and similar agencies in other countries) to review its approval of cochlear implantation in prelingually deaf children who are within the sensitive period for language acquisition. In the meantime, the FDA should require manufacturers to add a highlighted warning to the effect that results with CI vary widely and CIs should not be relied upon to provide adequate auditory input for complete language development in all deaf children. Recent best information on users' experience with CIs (including abandonment) should be clearly provided so that informed decisions can be made. The FDA should require manufacturers' guidance and information materials to include encouragement to parents of deaf children to offer auditory input of a spoken language and visual input of a sign language and to have their child followed closely from birth by developmental specialists in language and cognition. In this way parents can align with providers to prioritize cognitive development and language access in both audio-vocal and visuo-gestural modalities. DISCUSSION The arguments and recommendations in this paper are discussed at length as they come up.
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Affiliation(s)
- Tom Humphries
- Education Studies and Department of Communication, University of California at San Diego, La Jolla, CA, USA
| | | | - Gaurav Mathur
- Department of Linguistics, Gallaudet University, Washington, DC, USA
| | - Donna Jo Napoli
- Department of Linguistics, Swarthmore College, Swarthmore, PA, USA.
| | - Christian Rathmann
- Department of Deaf Studies and Sign Language Interpreting, Humboldt-Universität Zu Berlin, Berlin, Germany
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Rigorous and consistent evaluation of diagnostic tests in children: another unmet need. Pediatr Res 2020; 88:524-525. [PMID: 32892214 PMCID: PMC7493055 DOI: 10.1038/s41390-020-01110-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 12/03/2022]
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22
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Abstract
Currently, the majority of medical devices are designed for adults; some are then miniaturized for use in neonates. This process neglects population-specific testing that would ensure that the medical devices used for neonates are actually safe and effective for that group. Incorporating human-centered design principles and utilizing methods to evaluate devices that include simulation and clinical testing can improve the safety of devices used in caring for neonates. However, significant regulatory, financial, social and ethical barriers to development remain. In order to overcome these barriers and create a pipeline of safe and effective neonatal medical devices, specific incentives are required.
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Affiliation(s)
- Janene H Fuerch
- Division of Neonatal and Developmental Medicine, Stanford University Medical Center, United States.
| | | | - Immanuel Barshi
- Human System Integration Division, NASA Ames Research Center, United States
| | - Helen Liley
- Mater Mothers' Hospital and Mater Research - The University of Queensland, Faculty of Medicine, The University of Queensland, Australia
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23
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Strengthening the Evidence Base for Pediatric Medical Devices Using Real-World Data. J Pediatr 2019; 214:209-211. [PMID: 31378521 DOI: 10.1016/j.jpeds.2019.06.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/02/2019] [Accepted: 06/25/2019] [Indexed: 11/23/2022]
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Abstract
Medical devices are essential in the diagnosis and treatment of otolaryngologic disease. The US Food and Drug Administration (FDA) is tasked with assuring the safety and effectiveness of these devices. Otolaryngologists, in turn, are often responsible for helping patients understand risks, benefits, and alternatives when deciding whether to rely on devices in their care. To best counsel patients, otolaryngologists should be aware of the strengths and limitations of device regulation by the FDA. This article reviews the FDA regulatory framework for medical devices, premarket evidentiary standards for marketing devices, and postmarket methods of safety surveillance.
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Affiliation(s)
- Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
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25
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Augmented reality for personalized nanomedicines. Biotechnol Adv 2017; 36:335-343. [PMID: 29248686 DOI: 10.1016/j.biotechadv.2017.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 12/26/2022]
Abstract
As our understanding of onset and progress of diseases at the genetic and molecular level rapidly progresses, the potential of advanced technologies, such as 3D-printing, Socially-Assistive Robots (SARs) or augmented reality (AR), that are applied to personalized nanomedicines (PNMs) to alleviate pathological conditions, has become more prominent. Among advanced technologies, AR in particular has the greatest potential to address those challenges and facilitate the translation of PNMs into formidable clinical application of personalized therapy. As AR is about to adapt additional new methods, such as speech, voice recognition, eye tracing and motion tracking, to enable interaction with host response or biological systems in 3-D space, a combination of multiple approaches to accommodate varying environmental conditions, such as public noise and atmosphere brightness, will be explored to improve its therapeutic outcomes in clinical applications. For instance, AR glasses still being developed by Facebook or Microsoft will serve as new platform that can provide people with the health information they are interested in or various measures through which they can interact with medical services. This review has addressed the current progress and impact of AR on PNMs and its application to the biomedical field. Special emphasis is placed on the application of AR based PNMs to the treatment strategies against senior care, drug addiction and medication adherence.
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Incremental Revisions across the Life Span of Ophthalmic Devices after Initial Food and Drug Administration Premarket Approval, 1979-2015. Ophthalmology 2017; 124:1237-1246. [PMID: 28501378 DOI: 10.1016/j.ophtha.2017.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To characterize the frequency, nature, and regulatory mechanisms by which ophthalmic devices are iteratively modified after initial Food and Drug Administration (FDA) Premarket Approval (PMA). DESIGN Retrospective cross-sectional analysis using publicly available FDA data. PARTICIPANTS Ophthalmic devices initially approved via the FDA's PMA pathway between January 1, 1979 and December 31, 2015. METHODS We used the FDA's PMA Database to identify and characterize initial approvals and subsequent postmarket modifications to Class III ophthalmic devices. The FDA Recalls Database was used to identify associated safety events. MAIN OUTCOME MEASURES Median iterated life span (timespan across which modifications occurred after initial PMA) and median number of supplements approved per device, by device type, and overall, stratified by regulatory pathway and modification type. RESULTS Between 1979 and 2015, the FDA approved 168 original ophthalmic devices via the PMA pathway and 2813 subsequent modifications. More than one third (n = 64; 38%) of original approvals were intraocular lenses. Overall, devices underwent a median of 11 postmarket modifications (interquartile range [IQR], 3-24.8) across a median 10.0-year iterated life span (IQR, 4.1-16.7). The majority of devices (n = 144; 86%) underwent more than 1 postapproval modification, including more than 1 design modification (n = 84; 50%). The median number of changes altering device design or labeling was 3.5 (IQR, 1-9). Although manufacturing alterations (n = 834 of 2813; 30%) were the most frequent type of revision, changes involving device design (n = 667; 24%) and labeling (n = 417; 15%) were common. Recalled devices underwent more frequent postapproval modifications per year (median, 1.4; IQR, 0.7-2.3; mean, 1.5; 95% confidence interval, 1.1-1.9) in the period preceding recall than did nonrecalled devices (median, 0.5; IQR, 0.2-1.1; mean, 0.8; 95% confidence interval, 0.7-1.0) across their market approval period (P < 0.001). CONCLUSIONS Most ophthalmic devices approved via the FDA's PMA pathway have undergone extensive revisions, including serial design and labeling changes, since their initial approvals, often without supporting clinical data. Ophthalmologists should take into consideration that cumulative revisions may render the clinical evidence that supported an original FDA approval less relevant to newer device models.
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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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Rathi VK, Wang B, Ross JS, Downing NS, Kesselheim AS, Gray ST. Clinical Evidence Supporting US Food and Drug Administration Premarket Approval of High-Risk Otolaryngologic Devices, 2000-2014. Otolaryngol Head Neck Surg 2017; 156:285-288. [DOI: 10.1177/0194599816684094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Vinay K. Rathi
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Bo Wang
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nicholas S. Downing
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepi- demiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Stacey T. Gray
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Despite widespread therapeutic needs, the majority of medical and surgical devices used in children do not have approval or clearance from the Food and Drug Administration (FDA) for use in pediatric populations. The clinical need for devices to diagnose and treat diseases or conditions occurring in children has led to the widespread and necessary practice in pediatric medicine and surgery of using approved devices for "off-label" or "physician-directed" applications that are not included in FDA-approved labeling. This practice is common and often appropriate, even with the highest-risk (class III) devices. The legal and regulatory framework used by the FDA for devices is complex, and economic or market barriers to medical and surgical device development for children are significant. Given the need for pediatric medical and surgical devices and the challenges to pediatric device development, off-label use is a necessary and appropriate part of care. In addition, because of the relatively uncommon nature of pediatric conditions, FDA clearance or approval often requires other regulatory pathways (eg, Humanitarian Device Exemption), which can cause confusion among pediatricians and payers about whether a specific use, even of an approved device, is considered experimental. This policy statement describes the appropriateness of off-label use of devices in children; the use of devices approved or cleared through the FDA regulatory processes, including through the Humanitarian Device Exemption; and the important need to increase pediatric device labeling information for all devices and especially those that pose the highest risk to children.
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Affiliation(s)
- Joy H. Samuels-Reid
- Division of Anesthesiology, General Hospital, Respiratory, Infection Control, and Dental Devices, Office of Device Evaluation, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Judith U. Cope
- Office of Pediatric Therapeutics, Office of Special Medical Programs, Office of the Commissioner, US Food and Drug Administration, Silver Spring, Maryland
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Willis AR, Ippolito JA, Patterson FR, Benevenia J, Beebe KS. Customizable orthopaedic oncology implants: one institution's experience with meeting current IRB and FDA requirements. SPRINGERPLUS 2016; 5:967. [PMID: 27429877 PMCID: PMC4932010 DOI: 10.1186/s40064-016-2696-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 06/27/2016] [Indexed: 11/17/2022]
Abstract
Background Customizable orthopaedic implants are often needed for patients with primary malignant bone tumors due to unique anatomy or complex mechanical problems. Currently, obtaining customizable orthopaedic implants for orthopaedic oncology patients can be an arduous task involving submitting approval requests to the Institutional Review Board (IRB) and the Food and Drug Administration (FDA). There is great potential for the delay of a patient’s surgery and unnecessary paperwork if the submission pathways are misunderstood or a streamlined protocol is not in place. Purpose The objective of this study was to review the existing FDA custom implant approval pathways and to determine whether this process was improved with an institutional protocol. Methods An institutional protocol for obtaining IRB and FDA approval for customizable orthopaedic implants was established with the IRB at our institution in 2013. This protocol was approved by the IRB, such that new patients only require submission of a modification to the existing protocol with individualized patient information. During the two-year period of 2013–2014, eight patients were retrospectively identified as having required customizable implants for various orthopaedic oncology surgeries. The dates of request for IRB approval, request for FDA approval, and total time to surgery were recorded, along with the specific pathway utilized for FDA approval. Results The average patient age was 12 years old (7–21 years old). The average time to IRB approval of a modification to the pre-approved protocol was 14 days (7–21 days). Average time to FDA approval after submission of the IRB approval to the manufacturer was 12.5 days (7–19 days). FDA approval was obtained for all implants as compassionate use requests in accordance with Section 561 of the Federal Food Drug and Cosmetic Act’s expanded access provisions. Conclusions Establishment of an institutional protocol with pre-approval by the IRB can expedite the otherwise time-consuming and complicated process of obtaining customizable orthopaedic implants for orthopaedic oncology patients. Level of evidence Retrospective case series, Level IV. See the Guidelines for authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Joseph A Ippolito
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
| | - Francis R Patterson
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
| | - Joseph Benevenia
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
| | - Kathleen S Beebe
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
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Affiliation(s)
- Joseph S Ross
- From Section of General Internal Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine; Department of Health Policy and Management, Yale University School of Public Health; and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R.); and Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (A.S.K.).
| | - Aaron S Kesselheim
- From Section of General Internal Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine; Department of Health Policy and Management, Yale University School of Public Health; and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R.); and Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (A.S.K.)
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Zeitler EP, Al-Khatib SM, Slotwiner D, Kumar UN, Varosy P, Van Wagoner DR, Marcus GM, Kusumoto FM, Blum L. Proceedings from Heart Rhythm Society's emerging technologies forum, Boston, MA, May 12, 2015. Heart Rhythm 2016; 13:e39-49. [PMID: 26801401 PMCID: PMC4724379 DOI: 10.1016/j.hrthm.2015.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Indexed: 11/15/2022]
Abstract
Physicians are in an excellent position to significantly contribute to medical device innovation, but the process of bringing an idea to the bedside is complex. To begin to address these perceived barriers, the Heart Rhythm Society convened a forum of stakeholders in medical device innovation in conjunction with the 2015 Heart Rhythm Society Annual Scientific Sessions. The forum facilitated open discussion on medical device innovation, including obstacles to physician involvement and possible solutions. This report is based on the themes that emerged. First, physician innovators must take an organized approach to identifying unmet clinical needs and potential solutions. Second, extensive funds, usually secured through solicitation for investment, are often required to achieve meaningful progress, developing an idea into a device. Third, planning for regulatory requirements of the US Food and Drug Administration and Centers for Medicare & Medicaid Services is essential. In addition to these issues, intellectual property and overall trends in health care, including international markets, are critically relevant considerations for the physician innovator. Importantly, there are a number of ways in which professional societies can assist physician innovators to navigate the complex medical device innovation landscape, bring clinically meaningful devices to market more quickly, and ultimately improve patient care. These efforts include facilitating interaction between potential collaborators through scientific meetings and other gatherings; collecting, evaluating, and disseminating state-of-the-art scientific information; and representing the interests of members in interactions with regulators and policymakers.
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Affiliation(s)
- Emily P Zeitler
- Duke Clinical Research Institute; Duke University Hospital, Durham, North Carolina.
| | - Sana M Al-Khatib
- Duke Clinical Research Institute; Duke University Hospital, Durham, North Carolina
| | | | - Uday N Kumar
- Biodesign Program, Stanford University, Stanford, California
| | - Paul Varosy
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David R Van Wagoner
- Cleveland Clinic Lerner College of Medicine, Case Western Research University, Cleveland, Ohio
| | - Gregory M Marcus
- University of California, San Francisco, San Francisco, California
| | | | - Laura Blum
- Heart Rhythm Society, Washington, District of Columbia
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Amirav I, Halamish A, Gorenberg M, Omar H, Newhouse MT. More Realistic Face Model Surface Improves Relevance of Pediatric In-Vitro Aerosol Studies. PLoS One 2015; 10:e0128538. [PMID: 26090661 PMCID: PMC4474798 DOI: 10.1371/journal.pone.0128538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 04/28/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Various hard face models are commonly used to evaluate the efficiency of aerosol face masks. Softer more realistic "face" surface materials, like skin, deform upon mask application and should provide more relevant in-vitro tests. Studies that simultaneously take into consideration many of the factors characteristic of the in vivo face are lacking. These include airways, various application forces, comparison of various devices, comparison with a hard-surface model and use of a more representative model face based on large numbers of actual faces. AIM To compare mask to "face" seal and aerosol delivery of two pediatric masks using a soft vs. a hard, appropriately representative, pediatric face model under various applied forces. METHODS Two identical face models and upper airways replicas were constructed, the only difference being the suppleness and compressibility of the surface layer of the "face." Integrity of the seal and aerosol delivery of two different masks [AeroChamber (AC) and SootherMask (SM)] were compared using a breath simulator, filter collection and realistic applied forces. RESULTS The soft "face" significantly increased the delivery efficiency and the sealing characteristics of both masks. Aerosol delivery with the soft "face" was significantly greater for the SM compared to the AC (p< 0.01). No statistically significant difference between the two masks was observed with the hard "face." CONCLUSIONS The material and pliability of the model "face" surface has a significant influence on both the seal and delivery efficiency of face masks. This finding should be taken into account during in-vitro aerosol studies.
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Affiliation(s)
- Israel Amirav
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Ziv Medical Center, Safed, Israel
- * E-mail:
| | | | | | - Hamza Omar
- Nuclear Medicine Department, Ziv Medical Center, Safed, Israel
| | - Michael T. Newhouse
- Firestone Institute for Respiratory Health, St. Joseph’s Hospital, McMaster University, Hamilton, Ontario, Canada
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35
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Rathi VK, Ross JS, Samuel AM, Mehra S. Postmarket Modifications of High-Risk Therapeutic Devices in Otolaryngology Cleared by the US Food and Drug Administration. Otolaryngol Head Neck Surg 2015; 153:400-8. [DOI: 10.1177/0194599815587508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 04/28/2015] [Indexed: 11/16/2022]
Abstract
Objective: The US Food and Drug Administration (FDA) grants initial marketing clearance for novel high-risk medical devices via the premarket approval (PMA) pathway, which requires clinical data demonstrating safety and effectiveness. Manufacturers may subsequently file supplemental PMA applications (supplements) to implement incremental device changes, usually without additional clinical data. Given the potentially significant clinical implications of using new device models, this study characterized the frequency and nature of changes to high-risk therapeutic otolaryngic devices cleared via the PMA pathway. Study Design: Retrospective cohort study. Setting: FDA PMA database. Methods: Original high-risk therapeutic otolaryngic devices and supplements were identified. Supplements were characterized by clearance date, change type, and review track, including real-time (design-minor) and 180-day (design-major) tracks. Median device lineage life span (postmarket period over which changes occurred) and median number of changes per original device were calculated. Results: Through 2014, the FDA cleared 14 original high-risk therapeutic otolaryngic devices via the PMA pathway and 528 incremental changes via supplements. Devices were modified over a median 10.5-year life span (interquartile range, 4.4-15.8; range, 0.7-24.1), and they underwent a median 22 changes (interquartile range, 10-70; range, 2-108). Over half (272 of 528; 52%) altered device design, most of which were reviewed via the 180-day track (199 of 272; 73%) intended for major design changes. Few real-time design changes (11 of 73; 15%) were designated by the FDA as “minor.” Conclusion: A substantial number of incremental changes have been made to high-risk therapeutic otolaryngic devices over time, including many major design changes without supporting clinical data.
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Affiliation(s)
- Vinay K. Rathi
- Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Saral Mehra
- Department of Surgery (Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, New Haven, Connecticut
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Hwang J, Hwang TJ, Ciolino JB. Pivotal clinical trials of novel ophthalmic drugs and medical devices: retrospective observational study, 2002-2012. BMJ Open 2015; 5:e007987. [PMID: 26044760 PMCID: PMC4458635 DOI: 10.1136/bmjopen-2015-007987] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Novel therapeutics are an important part of ophthalmologists' armamentarium, and the risks and benefits of these therapies must be carefully evaluated. We sought to quantify the characteristics of the pivotal clinical trials supporting the regulatory approval of new ophthalmic drugs and medical devices. DESIGN Retrospective observational study. SETTING AND DATA SOURCE Medical review dossiers for new ophthalmic drug and high-risk device approvals released publicly by the US Food and Drug Administration (FDA). MAIN OUTCOME MEASURES Proportion of pivotal trials with randomisation, masking, active or placebo controls and subgroup analyses; total and median number of trial enrollees; and the number of drugs and devices approved with required postapproval studies. RESULTS From 2002 to 2012, the FDA approved 11 ophthalmic drugs and 25 devices. The pivotal trials underlying the approvals of ophthalmic drugs in our study cohort enrolled a median of 809 patients. Virtually all drug trials were randomised and masked (91%), of which 7 (70%) used a placebo control. Pivotal trials for ophthalmic devices enrolled 324 patients on average, and significantly fewer trials for ophthalmic devices versus drugs were randomised (16% vs 91%; p<0.001) or masked (12% vs 91%; p<0.001). 8 (32%) ophthalmic devices and 6 (55%) ophthalmic drugs were approved with required postapproval studies. CONCLUSIONS Ophthalmic therapeutics were approved based on varying levels of evidence. Postapproval studies could be used to confirm or refute early indications of safety and effectiveness of these therapeutics, with the study results accessible to patients and clinicians who need to make informed treatment decisions.
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Affiliation(s)
- Jenny Hwang
- St John's Riverside Hospital, Yonkers, New York, USA
| | - Thomas J Hwang
- Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts, USA The Blackstone Group, London, UK
| | - Joseph B Ciolino
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Rising JP, Moscovitch B. Characteristics of pivotal trials and FDA review of innovative devices. PLoS One 2015; 10:e0117235. [PMID: 25651420 PMCID: PMC4317185 DOI: 10.1371/journal.pone.0117235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/20/2014] [Indexed: 11/22/2022] Open
Abstract
When patients lack sufficient treatment options for serious medical conditions, they rely on the prompt approval and development of new therapeutic alternatives, such as medical devices. Understanding the development of innovative medical devices, including the characteristics of premarket clinical trials and length of Food and Drug Administration (FDA) review, can help identify ways to expedite patient access to novel technologies and inform recent efforts by FDA to more quickly get these products to patients and physicians. We analyzed publicly available information on clinical trials and premarket FDA review for innovative medical devices that fill an unmet medical need. In this first-of-its-kind study focusing on these products, we extracted data on the length of the pivotal trials, primary study endpoint and FDA review; number of patients enrolled in trials; and in what country the device was available first. We identified 27 approved priority review devices from January 2006 through August 2013. The median duration of pivotal clinical trials was 3 years, ranging from 3 months to approximately 7 years. Trials had a median primary outcome measure evaluation time of one year and a median enrollment of 297 patients. The median FDA review time was 1 year and 3 months. Most priority review devices were available abroad before they were approved in the United States. Our study indicates that addressing the length of clinical studies--and contributing factors, such as primary outcome measures and enrollment--could expedite patient access to innovative medical devices. FDA, manufacturers, Congress and other stakeholders should identify the contributing factors to the length of clinical development, and implement appropriate reforms to address those issues.
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Affiliation(s)
- Joshua P Rising
- The Pew Charitable Trusts, Washington, District of Columbia, United States of America
| | - Ben Moscovitch
- The Pew Charitable Trusts, Washington, District of Columbia, United States of America
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Affiliation(s)
- Thomas J. Hwang
- Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts; and The Blackstone Group, London, England
| | - Florence T. Bourgeois
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts; and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Davis NJ. Transcranial stimulation of the developing brain: a plea for extreme caution. Front Hum Neurosci 2014; 8:600. [PMID: 25140146 PMCID: PMC4122183 DOI: 10.3389/fnhum.2014.00600] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/18/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nick J Davis
- Department of Psychology, Swansea University Swansea, UK
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