Post-trial access to implantable neural devices: an exploratory international survey

Objectives

Clinical trials of innovative neural implants are rapidly increasing and diversifying, but little is known about participants' post-trial access to the device and ongoing clinical care. This exploratory study examines common practices in the planning and coordination of post-trial access to neurosurgical devices. We also explore the perspectives of trial investigators on the barriers to post-trial access and ongoing care, as well as ethical questions related to the responsibilities of key stakeholder groups.

Design setting and participants

Trial investigators (n=66) completed a survey on post-trial access in the most recent investigational trial of a surgically implanted neural device they had conducted. Survey respondents predominantly specialized in neurosurgery, neurology and psychiatry, with a mean of 14.8 years of experience working with implantable neural devices.

Main outcome measures

Outcomes of interest included rates of device explantation during or at the conclusion of the trial (pre-follow-up) and whether plans for post-trial access were described in the study protocol. Outcomes also included investigators' greatest 'barrier' and 'facilitator' to providing research participants with post-trial access to functional implants and perspectives on current arrangements for the sharing of post-trial responsibilities among key stakeholders.

Results

Trial investigators reported either 'all' (64%) or 'most' (33%) trial participants had remained implanted after the end of the trial, with 'infection' and 'non-response' the most common reasons for explantation. When asked to describe the main barriers to facilitating post-trial access, investigators described limited funding, scarcity of expertise and specialist clinical infrastructure and difficulties maintaining stakeholder relationships. Notwithstanding these barriers, investigators overwhelmingly (95%) agreed there is an ethical obligation to provide post-trial access when participants individually benefit during the trial.

Conclusions

On occasions when devices were explanted during or at the end of the trial, this was done out of concern for the safety and well-being of participants. Further research into common practices in the post-trial phase is needed and essential to ethical and pragmatic discussions regarding stakeholder responsibilities.

Devices and furniture for small and sick newborn care: systematic development of a planning and costing tool

BACKGROUND

High-quality neonatal care requires sufficient functional medical devices, furniture, fixtures, and use by trained healthcare workers, however there is lack of publicly available tools for quantification and costing. This paper describes development and use of a planning and costing tool regarding furniture, fixtures and devices to support scale-up of WHO level-2 neonatal care, for national and global newborn survival targets.

METHODS

We followed a systematic process. First, we reviewed planning and costing tools of relevance. Second, we co-designed a new tool to estimate furniture and device set-up costs for a default 40-bed level-2 neonatal unit, incorporating input from multi-disciplinary experts and newborn care guidelines. Furniture and device lists were based off WHO guidelines/norms, UNICEF and national manuals/guides. Due to lack of evidence-based quantification, ratios were based on operational manuals, multi-country facility assessment data, and expert opinion. Default unit costs were from government procurement agency costs in Kenya, Nigeria, and Tanzania. Third, we refined the tool by national use in Tanzania.

RESULTS

The tool adapts activity-based costing (ABC) to estimate quantities and costs to equip a level-2 neonatal unit based on three components: (1) furniture/fixtures (18 default but editable items); (2) neonatal medical devices (16 product categories with minimum specifications for use in low-resource settings); (3) user training at device installation. The tool was used in Tanzania to generate procurement lists and cost estimates for level-2 scale-up in 171 hospitals (146 District and 25 Regional Referral). Total incremental cost of all new furniture and equipment acquisition, installation, and user training were US$93,000 per District hospital (level-2 care) and US$346,000 per Regional Referral hospital. Estimated cost per capita for whole-country district coverage was US$0.23, representing 0.57% increase in government health expenditure per capita and additional 0.35% for all Regional Referral hospitals.

CONCLUSION

Given 2.3 million neonatal deaths and potential impact of level-2 newborn care, rational and efficient planning of devices linked to systems change is foundational. In future iterations, we aim to include consumables, spare parts, and maintenance cost options. More rigorous implementation research data are crucial to formulating evidence-based ratios for devices numbers per baby. Use of this tool could help overcome gaps in devices numbers, advance efficiency and quality of neonatal care.

Comparison of the international regulations for medical devices-USA versus Europe

In May 2021, the new Medical Device Regulation in the EU came into force. While the US has a centralized governmental authority, the Food and Drug Administration (FDA), the EU implemented a system of different Notified Bodies responsible for the approval process of medical devices. Both regions have a similar system to classify medical devices based on their overall risks but specific devices, like joint prostheses, are classified differently in the US and the EU. Depending on the risk class, there are differences in the quality and quantity of clinical data required to obtain market approval. In both regions, it is possible to place a new device on the market based on the demonstration of equivalence to an already marketed device, but the MDR significantly increased the regulatory requirements for the equivalence pathway. While an approved medical device in the US in most cases only requires general post-market surveillance activities, manufacturers in the EU must continuously collect clinical data and submit specific reports to the Notified Bodies. In this article, we will compare the regulatory requirements between the US and Europe and provide an overview of similarities and differences.

Advances in Treatment of Isocitrate Dehydrogenase (IDH)-Wildtype Glioblastomas

PURPOSE OF REVIEW

The management of isocitrate dehydrogenase (IDH)-wildtype glioblastomas is an area of unmet need. Despite multimodal therapy incorporating maximal safe resection, radiotherapy, and temozolomide, clinical outcomes remain poor. At disease progression or relapse, available systemic agents such as temozolomide, lomustine, and bevacizumab have limited efficacy. We review the recent advances in the treatment of IDH-wildtype glioblastomas.

RECENT FINDINGS

A broad repertoire of systemic agents is in the early stages of development, encompassing the areas of precision medicine, immunotherapy, and repurposed medications. The use of medical devices may present opportunities to bypass the blood-brain barrier. Novel clinical trial designs aim to efficiently test treatment options to advance the field. There are a number of emerging treatment options for IDH-wildtype glioblastomas which are undergoing evaluation in clinical trials. Advances in our scientific understanding of IDH-wildtype glioblastomas offer hope and the prospect of incremental improvements in clinical outcomes.

MedSecurance Project: Advanced Security-for-Safety Assurance for Medical Device IoT (IoMT)

The MedSecurance project focus on identifying new challenges in cyber security with focus on hardware and software medical devices in the context of emerging healthcare architectures. In addition, the project will review best practice and identify gaps in the guidance, particularly the guidance stipulated by the medical device regulation and directives. Finally, the project will develop comprehensive methodology and tooling for the engineering of trustworthy networks of inter-operating medical devices, that shall have security-for-safety by design, with a strategy for device certification and certifiable dynamic network composition, ensuring that patient safety is safeguarded from malicious cyber actors and technology "accidents".

Benchtop assessment of sealing efficacy and breathability of additively manufactured (AM) face masks

The onset of the 2019 novel coronavirus disease (COVID-19) led to a shortage of personal protective equipment (PPE), medical devices, and other medical supplies causing many stakeholders and the general public alike to turn to additive manufacturing (AM) as a stopgap when normally accessible devices were not available. However, without a method to test these AM constructs, there continued to be a disconnect between AM suppliers and the community's needs. The objective of this study was to characterize the pressure drop and leakage of four different publicly available AM face mask models with two filter material combinations, as well as to investigate the impact of frame modification techniques including the use of foam strips and hot-water face forming to improve fit when the masks are donned on manikin head forms. AM face mask frame designs were downloaded from public repositories during the early stages of the COVID-19 pandemic. AM face masks were fabricated and tested on manikin head forms within a custom chamber containing dry aerosolized NaCl. Pressure drops, particle penetration, and leakage were evaluated for various flow rates and NaCl concentrations. Results indicated that filter material combination and frame modification played a major role in the overall performance of the AM face masks studied. Filter material combinations showed improved performance when high filtration fabric was used, and the cross-sectional area of the fabric was increased. AM frame modifications appeared to improve AM face mask leakage performance by as much as 69.6%.

American and European legislation on border medical devices

INTRODUCTION

Borderline medical devices are products in a "gray area", this means due to their characteristics, they could belong to different "legal products". In addition, regulation is a controversial topic and may change depending on the country which may put public health at risk and distort the market.

AREAS COVERED

This article analyzes how borderline medical devices are managed in the American and the European legislation. We compared the decisions made by both regulations on the devices of the "Manual on Borderline and Classification Medical Devices" of the European Commission for the first three sections, those which deal exclusively with medical devices.

EXPERT OPINION

Borderline medical devices do not have to be understood as something specific to each country. The different classification of products creates international borders. It is necessary to create working groups in international organizations in which global consensus is reached. Although a priori it seems that the American system could be more efficient, studies with quantitative data from authorized devices are needed to show that. Until EUDAMED is not fully operational and open access, it will not be possible to develop them.

A Hand Motion Tracker Supporting Home-Based Rehabilitation for People with Hemiplegia due to Stroke

Modern Wearable Medical Devices (WMDs), implement capabilities that have contributed significantly to patient outcomes, as well as quality of life. Using such devices can be beneficial for many patients, especially during the time of the pandemic where everyone had to isolate at home. This paper presents a proof of concept of a new low-cost technology-based approach to support home-based rehabilitation for people with hemiplegia aiming to assess the effectiveness of their home-based exercises thus making telerehabilitation sessions more effective.

FHIR Based Interoperability of Medical Devices

Although FHIR has been designed to be easy to implement, it requires knowledge that is still hard to find. We aim to evaluate the use of FHIR in Portuguese projects for the integration of medical devices. Two projects were selected, including easyHealth4Covid (EH4C) and Chronic Diseases Management Platform (CDMP). The evolution of each project and the FHIR resources used were analyzed. 11 different sensors of 5 companies were used in the sum of both projects. Previously, none of them used FHIR to integrate and the teams had little to no experience in doing so. The FHIR Observation resource was used for all. There is a general lack of knowledge of the FHIR standard and terminologies of most of the device companies involved in the projects.

Comparison of outpatient coverage in Canada: Assistive and medical devices

Outpatient technologies are important for maintaining health and overall quality of life, yet the degree of access and coverage of these technologies remains variable within and across jurisdictions. In Canada, assistive technologies are not included in universal health coverage, and are not subject to the Canada Health Act's criteria and conditions that provinces and territories must fulfill to receive the full federal cash contribution under the Canada Health Transfer. As such, the thirteen Canadian provincial and territorial governments make separate decisions on programs and coverage. Drawing on the WHO Universal Coverage Cube we compare who gets access, the types of technologies that can be accessed, and the level of coverage (total costs covered) in Canada. Overall, each Canadian jurisdiction had at least one publicly supported program. All relied on a 'health assessment' of an individual's need to determine eligibility. Income and eligibility for social assistance was used as eligibility criteria in 6 of the 13 jurisdictions. Mobility aids as well as audio, visual, and communication aids were included in all jurisdictions. While some programs offered full financial support for some technologies, forms of cost sharing were common. The results are discussed in the context of international experiences, demographic changes, and health system trends to highlight areas for policy learning.

Research and Development Strategy for Future Embryonic Stem Cell-Based Therapy in Japan

Herewith, we review an updated progress of regenerative medical products using human embryonic stem cells (ESCs) in Japan. Two groups from Kyoto University and the National Center for Child Health and Development (NCCHD) established a novel derivation/cultivation system of ESCs for potential application in translational and clinical research. At the first stage of ESC derivation, murine feeder cells have been used in line with Japanese guidelines on public health associated with the implementation of the xenograft. To avoid exposure of ESCs to animal products in culture media, a xeno-free cultivating system has been established. Twelve ESCs (KhES-1, KhES-2, KhES-3, KhES-4, KhES-5, SEES-1, SEES-2, SEES-3, SEES-4, SEES-5, SEES-6, and SEES-7) are now available under a clinically relevant platform for industrially and clinically applicable regenerative medical products. NCCHD submitted an investigative new drug application to the Pharmaceuticals and Medical Devices Agency (PMDA) for using ESC-based products in patients with hyperammonemia due to genetic defects on March 2018 under the Pharmaceutical Affairs Law (now revised to the Pharmaceuticals, Medical Devices, and Other Therapeutic Products Act). Currently, up to ten ESC-based products are being prepared for intractable and rare disorders in Japan.

Decoupling Steerability from Diameter: Helical Dovetail Laser Patterning for Steerable Needles

The maximum curvature of a steerable needle in soft tissue is highly sensitive to needle shaft stiffness, which has motivated use of small diameter needles in the past. However, desired needle payloads constrain minimum shaft diameters, and shearing along the needle shaft can occur at small diameters and high curvatures. We provide a new way to adjust needle shaft stiffness (thereby enhancing maximum curvature, i.e. "steerability") at diameters selected based on needle payload requirements. We propose helical dovetail laser patterning to increase needle steerability without reducing shaft diameter. Experiments in phantoms and ex vivo animal muscle, brain, liver, and inflated lung tissues demonstrate high steerability in soft tissues. These experiments use needle diameters suitable for various clinical scenarios, and which have been previously limited by steering challenges without helical dovetail patterning. We show that steerable needle targeting remains accurate with established controllers and demonstrate interventional payload delivery (brachytherapy seeds and radiofrequency ablation) through the needle. Helical dovetail patterning decouples steerability from diameter in needle design. It enables diameter to be selected based on clinical requirements rather than being carefully tuned to tissue properties. These results pave the way for new sensors and interventional tools to be integrated into high-curvature steerable needles.

Early Health Economic Modelling - Optimizing Development for Medical Device Developers? Comment on "Problems and Promises of Health Technologies: The Role of Early Health Economic Modeling"

This commentary considers the positive and negative consequences of early economic modelling and explores potential future directions. Early economic modelling offers device manufacturers an opportunity to assess the potential value of an innovation at an early stage of development. Early modelling can direct resources into potentially viable technologies and reduce investment in technologies with limited prospect of value. However, it is unclear whether early modelling is sufficiently specific to identify innovations with low value. It may be that early modelling is more useful for directing data gathering to reduce decision uncertainty. Early modelling is of primary benefit to the manufacturer and may have both positive and negative consequences for reimbursement processes that should be considered.

Health Technology Assessment and Biomedical Engineering: Global trends, gaps and opportunities

The diffusion of medical devices is expanding at an astonishing rate. The increasing number of novel patents per year suggests this growth will continue. In contrast to drugs, medical devices are intrinsically dependent on the environment in which they are used and how they are maintained. This created an unprecedented global need for well-trained biomedical engineers who can help healthcare systems to assess them. The International Federation for Medical and Biological Engineering (IFMBE) is the global scientific society of biomedical engineers in official relations with the United Nations World Health Organisation (WHO) and has been very active in promoting the role of the biomedical engineer in Health Technology Assessment (HTA). The IFMBE Health Technology Assessment Division (HTAD) is the IFMBE operative branch in this field, promoting studies, projects and activities to foster the growth of this specific and very important science sector, including summer schools, training material, an HTA eLearning platform, HTA guidelines, awards and more. This article describes the vision, the mission and the strategy of the HTAD, with a focus on the results achieved and the impact this is having on global policymaking.

Drug Delivery Technology Development in Canada

Canada has a long and rich history of ground-breaking research in drug delivery within academic institutions, pharmaceutical industry and the biotechnology community. Drug delivery refers to approaches, formulations, technologies, and systems for transporting a pharmaceutical compound in the body as needed to safely achieve its desired therapeutic effect. It may involve rational site-targeting, or facilitating systemic pharmacokinetics; in any case, it is typically concerned with both quantity and duration of the presence of the drug in the body. Drug delivery is often approached through a drug’s chemical formulation, medical devices or drug-device combination products. Drug delivery is a concept heavily integrated with dosage form development and selection of route of administration; the latter sometimes even being considered part of the definition. Drug delivery technologies modify drug release profile, absorption, distribution and elimination for the benefit of improving product efficacy and safety, as well as patient convenience and adherence. Over the past 30 years, numerous Canadian-based biotechnology companies have been formed stemming from the inventions conceived and developed within academic institutions. Many have led to the development of important drug delivery products that have enhanced the landscape of drug therapy in the treatment of cancer to infectious diseases. This Special Issue serves to highlight the progress of drug delivery within Canada. We invited articles on all aspects of drug delivery sciences from pre-clinical formulation development to human clinical trials that bring to light the world-class research currently undertaken in Canada for this Special Issue.

Reprocessing semicritical items: Outbreaks and current issues

Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (eg, gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection. As many of these items are temperature sensitive, low-temperature chemical methods must be used rather than steam sterilization. Strict adherence to current guidelines is required as more outbreaks have been linked to inadequately cleaned or disinfected endoscopes and other semicritical items than any other reusable medical devices.

Developing an Evidence-Based Clinical Dataset for the Comprehensive Implantable Medical Device Registry (CIMDR)

Medical registries are in a need of a data set that is based on clinical evidence. In 2014, the Saudi Food and Drug Administration (SFDA) launched a plan to develop the national Comprehensive Implantable Medical Device Registry (CIMDR). One of the primary goals of the CIMDR is to develop a clinical -and population- based data set. The aim of this study is to report on the process of developing the data elements for the CIMDR. We used an iterative process of multi-stakeholder consultation over a two year period (2014-2016). The goal of the multi-stakeholder consultations was to build a dataset to address the need for device traceability, effectiveness, safety, and the recall of implantable medical devices. We investigated international and local standards for implantable medical device information capture, conducted a review of the literature, and consulted expert opinions in the development of the CIMDR dataset. The CIMDR data framework includes demographics, patient history, diagnosis, procedure information, and follow-up details for orthopedic and cardiac related implantable medical devices. Most of the dataset elements are logically validated with minimal free text entry to avoid human error and facilitate ease of entry. We use the International Classification for Diseases-Australian Modification as the standardized nomenclature for the CIMDR.

Factors Influencing the Implementation and Distribution of Clinical Decision Support Systems (CDSS)

Clinical Decision Support Systems (CDSS) can have positive effects on quality of care measures, yet have not gained widespread traction in healthcare. This study sought to determine and evaluate barriers and facilitators to CDSS implementation and distribution. Based on 768 systems identified in a literature review we conducted semi-structured telephone interviews with 54 system developers in 16 countries. Qualitative analysis led to the identification of 66 key factors influencing implementation. Central issues evolved around CDSS properties, quality and integration, as well as usability, user related factors, internal marketing, resource issues and collaborations with emphasis partly on topics differing from existing research. Additionally, evidence pointed to regional differences regarding implementation hurdles. Recent regulatory requirements were deemed less of a barrier to system adoption than expected, even though lacking expertise in this area was surprisingly common among interview partners.

Propose of Standards Based IT Architecture to Enrich the Value of Allergy Data by Telemonitoring Data

Interoperability is a key requirement for any IT-System to be future proof and cost efficient, due to the increasing interaction of IT-Systems in Healthcare. This feasibility study is part of a larger project focusing on the conceptualization and evaluation of interoperable and modular IT-Framework components for exchanging big data information sets. Hence, this project investigates the applicability of a standard based IT-Architecture for the integration of Personal Health Devices data and open data sources. As a proof of concept use case, pollen forecast data from the Medical University of Vienna were combined with Personal Health Device data and a data correlation was investigated. The standards were identified as well as selected in expert's reviewed and the Architecture was designed based on a literature research. Subsequently the prototype was implemented and successfully tested in interoperability tests. The study shows that the architecture meets the requirements. It can be flexibly extended according to further requirements due to its generic setup. However, further extensions of the Interoperability-Connector and a full test setup needs to be realized in future.

Innovation under Regulatory Uncertainty: Evidence from Medical Technology

This paper explores how the regulatory approval process affects innovation incentives in medical technologies. Prior studies have found early mover regulatory advantages for drugs. I find the opposite for medical devices, where pioneer entrants spend 34 percent (7.2 months) longer than follow-on entrants in regulatory approval. Back-of-the- envelope calculations suggest that the cost of a delay of this length is upwards of 7 percent of the total cost of bringing a new high-risk device to market. Considering potential explanations, I find that approval times are largely unrelated to technological novelty, but are meaningfully reduced by the publication of objective regulatory guidelines. Finally, I consider how the regulatory process affects small firms' market entry patterns and find that small firms are less likely to be pioneers in new device markets, a fact consistent with relatively higher costs of doing so for more financially constrained firms.

Permcath catheter embolization: a case report

Introduction:

Nowadays, many types of intravascular devices and catheters are used in order to diagnose and treat diseases. Complications related to these instruments are the costs that doctors and patients have to pay to benefit from their advantages. Catheter embolization is one of these side effects. Patients with devices in their cardiopulmonary system are at risk for severe complications such as arrhythmias, pulmonary embolism, myocardial injuries, hemoptysis, thrombosis and perforation.

Case Presentation:

A 50-years-old woman, with a history of breast cancer, had a PermCath emplacement in right subclavian vein for a course of chemotherapy. The treatment for cancer seemed to be successful and the PermCath had remained in its position without complication, for a couple of years however, the catheter was founded broken and embolized to the right ventricle and the main left pulmonary artery, diagnosed by a chest X-ray study incidentally.

Conclusions:

It is better to remove the unused devices safely to prevent and decrease their possible complications.