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Siontis GCM, Coles B, Häner JD, McGovern L, Bartkowiak J, Coughlan JJ, Spirito A, Galea R, Haeberlin A, Praz F, Tomii D, Melvin T, Frenk A, Byrne RA, Fraser AG, Windecker S. Quality and transparency of evidence for implantable cardiovascular medical devices assessed by the CORE-MD consortium. Eur Heart J 2024; 45:161-177. [PMID: 37638967 DOI: 10.1093/eurheartj/ehad567] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS The European Union Medical Device Regulation 2017/745 challenges key stakeholders to follow transparent and rigorous approaches to the clinical evaluation of medical devices. The purpose of this study is a systematic evaluation of published clinical evidence underlying selected high-risk cardiovascular medical devices before and after market access in the European Union (CE-marking) between 2000 and 2021. METHODS Pre-specified strategies were applied to identify published studies of prospective design evaluating 71 high-risk cardiovascular devices in seven different classes (bioresorbable coronary scaffolds, left atrial appendage occlusion devices, transcatheter aortic valve implantation systems, transcatheter mitral valve repair/replacement systems, surgical aortic and mitral heart valves, leadless pacemakers, subcutaneous implantable cardioverter-defibrillator). The search time span covered 20 years (2000-21). Details of study design, patient population, intervention(s), and primary outcome(s) were summarized and assessed with respect to timing of the corresponding CE-mark approval. RESULTS At least one prospective clinical trial was identified for 70% (50/71) of the pre-specified devices. Overall, 473 reports of 308 prospectively designed studies (enrolling 97 886 individuals) were deemed eligible, including 81% (251/308) prospective non-randomized clinical trials (66 186 individuals) and 19% (57/308) randomized clinical trials (31 700 individuals). Pre-registration of the study protocol was available in 49% (150/308) studies, and 16% (48/308) had a peer-reviewed publicly available protocol. Device-related adverse events were evaluated in 82% (253/308) of studies. An outcome adjudication process was reported in 39% (120/308) of the studies. Sample size was larger for randomized in comparison to non-randomized trials (median of 304 vs. 100 individuals, P < .001). No randomized clinical trial published before CE-mark approval for any of the devices was identified. Non-randomized clinical trials were predominantly published after the corresponding CE-mark approval of the device under evaluation (89%, 224/251). Sample sizes were smaller for studies published before (median of 31 individuals) than after (median of 135 individuals) CE-mark approval (P < .001). Clinical trials with larger sample sizes (>50 individuals) and those with longer recruitment periods were more likely to be published after CE-mark approval, and were more frequent during the period 2016-21. CONCLUSIONS The quantity and quality of publicly available data from prospective clinical investigations across selected categories of cardiovascular devices, before and after CE approval during the period 2000-21, were deemed insufficient. The majority of studies was non-randomized, with increased risk of bias, and performed in small populations without provision of power calculations, and none of the reviewed devices had randomized trial results published prior to CE-mark certification.
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Affiliation(s)
- George C M Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Bernadette Coles
- Velindre University NHS Trust Library and Knowledge Service, Cardiff, UK
| | - Jonas D Häner
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Laurna McGovern
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Joanna Bartkowiak
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - J J Coughlan
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roberto Galea
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Tom Melvin
- School of Medicine, Trinity College Dublin, Ireland
| | - André Frenk
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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Schietzel S, Bally L, Cereghetti G, Faller N, Moor MB, Vogt B, Rintelen F, Trelle S, Fuster D. Impact of the SGLT2 inhibitor empagliflozin on urinary supersaturations in kidney stone formers (SWEETSTONE trial): protocol for a randomised, double-blind, placebo-controlled cross-over trial. BMJ Open 2022; 12:e059073. [PMID: 35288397 PMCID: PMC8921923 DOI: 10.1136/bmjopen-2021-059073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Kidney stones are a global healthcare problem. Given high recurrence rates and the morbidity associated with symptomatic stone disease, effective medical prophylaxis is clearly an unmet need. Explanatory analyses of randomised controlled trials with sodium/glucose cotransporter isoform 2 inhibitors indicated a 30%-50% reduced rate of stone events in patients with diabetes. Underlying mechanisms remain unclear. We aim to determine the effect of empagliflozin on urinary supersaturations in non-diabetic kidney stone formers to evaluate their therapeutic potential for recurrence prevention. We will provide first clinical trial evidence on whether urinary supersaturations are affected by empagliflozin in kidney stone formers. METHODS AND ANALYSIS The SWEETSTONE trial is a randomised, double-blind, placebo-controlled, cross-over, exploratory study to assess the impact of empagliflozin on urinary supersaturations of calcium oxalate, calcium phosphate and uric acid in kidney stone formers. We plan to include 46 non-diabetic adults (18-74 years) with ≥1 past kidney stone event and stone composition with ≥80% of calcium or ≥80% of uric acid. Patients with secondary causes of kidney stones or chronic kidney disease will be excluded. Eligible individuals will be randomised in equal proportions to receive either a 14-day treatment with 25 mg empagliflozin followed after the 2-6 weeks wash out period by a 14-day treatment with a matching placebo or the reverse procedure. Secondary outcomes will include electrolyte concentrations, renal function, mineral metabolism and glycaemic parameters, urinary volume and safety.Results will be presented as effect measures (95% CIs) with p values and hypothesis testing for primary outcomes (significance level 0.02). ETHICS AND DISSEMINATION The SWEETSTONE trial was approved by the Swiss ethics committee and Swissmedic. First results are expected in the fourth quarter of 2022. TRIAL REGISTRATION NUMBER NCT04911660; Pre-results.
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Affiliation(s)
- Simeon Schietzel
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Grazia Cereghetti
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - Nicolas Faller
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias B Moor
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bruno Vogt
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Felix Rintelen
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - S Trelle
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - Daniel Fuster
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Sidler D, Born A, Schietzel S, Horn MP, Aeberli D, Amsler J, Möller B, Njue LM, Medri C, Angelillo-Scherrer A, Borradori L, Seyed Jafari SM, Radonjic-Hoesli S, Chan A, Hoepner R, Bacher U, Mani LY, Iype JM, Suter-Riniker F, Staehelin C, Nagler M, Hirzel C, Maurer B, Moor MB. Trajectories of humoral and cellular immunity and responses to a third dose of mRNA vaccines against SARS-CoV-2 in patients with a history of anti-CD20 therapy. RMD Open 2022; 8:e002166. [PMID: 35361691 PMCID: PMC8971359 DOI: 10.1136/rmdopen-2021-002166] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/09/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The majority of patients with B-cell-depleting therapies show compromised vaccination-induced immune responses. Herein, we report on the trajectories of anti-SARS-CoV-2 immune responses in patients of the RituxiVac study compared with healthy volunteers and investigate the immunogenicity of a third vaccination in previously humoral non-responding patients. METHODS We investigated the humoral and cell-mediated immune response after SARS-CoV-2 messanger RNA vaccination in patients with a history with anti-CD20 therapies. Coprimary outcomes were antispike and SARS-CoV-2-stimulated interferon-γ concentrations in vaccine responders 4.3 months (median; IQR: 3.6-4.8 months) after first evaluation, and humoral and cell-mediated immunity (CMI) after a third vaccine dose in previous humoral non-responders. Immunity decay rates were compared using analysis of covariance in linear regression. RESULTS 5.6 months (IQR: 5.1-6.7) after the second vaccination, we detected antispike IgG in 88% (29/33) and CMI in 44% (14/32) of patients with a humoral response after two-dose vaccination compared with 92% (24/26) healthy volunteers with antispike IgG and 69% (11/16) with CMI 6.8 months after the second vaccination (IQR: 6.0-7.1). Decay rates of antibody concentrations were comparable between patients and controls (p=0.70). In two-dose non-responders, a third SARS-CoV-2 vaccine elicited humoral responses in 19% (6/32) and CMI in 32% (10/31) participants. CONCLUSION This study reveals comparable immunity decay rates between patients with anti-CD20 treatments and healthy volunteers, but inefficient humoral or CMI after a third SARS-CoV-2 vaccine in most two-dose humoral non-responders calling for individually tailored vaccination strategies in this population.Trial registration numberNCT04877496; ClinicalTrials.gov number.
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Affiliation(s)
- Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital University Hospital Bern, Bern, Switzerland
| | - Alexander Born
- Department of Nephrology and Hypertension, Inselspital University Hospital Bern, Bern, Switzerland
| | - Simeon Schietzel
- Department of Nephrology and Hypertension, Inselspital University Hospital Bern, Bern, Switzerland
| | - Michael P Horn
- Department of Clinical Chemistry, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Daniel Aeberli
- Department of Rheumatology and Immunology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Jennifer Amsler
- Department of Rheumatology and Immunology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Burkhard Möller
- Department of Rheumatology and Immunology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Linet M Njue
- Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital Bern, Bern, Switzerland
| | - Cesare Medri
- Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital Bern, Bern, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital Bern, Bern, Switzerland
| | - Luca Borradori
- Department of Dermatology, Inselspital University Hospital Bern, Bern, Switzerland
| | | | | | - Andrew Chan
- Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Robert Hoepner
- Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Ulrike Bacher
- Department of Haematology and Central Haematology Laboratory, Inselspital University Hospital Bern, Bern, Switzerland
| | - Laila-Yasmin Mani
- Department of Nephrology and Hypertension, Inselspital University Hospital Bern, Bern, Switzerland
| | - Joseena Mariam Iype
- Department of Clinical Chemistry, Inselspital Universitatsspital Bern, Bern, Switzerland
| | | | - Cornelia Staehelin
- Department of Infectious Diseases, Inselspital University Hospital Bern, Bern, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Cedric Hirzel
- Department of Infectious Diseases, Inselspital University Hospital Bern, Bern, Switzerland
| | - Britta Maurer
- Department of Rheumatology and Immunology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Matthias B Moor
- Department of Nephrology and Hypertension, Inselspital University Hospital Bern, Bern, Switzerland
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