Data sources and applied methods for paclitaxel safety signal discernment

Background

Following the identification of a late mortality signal, the Food and Drug Administration (FDA) convened an advisory panel that concluded that additional clinical study data are needed to comprehensively evaluate the late mortality signal observed with the use of drug-coated balloons (DCB) and drug-eluting stent (DES). The objective of this review is to (1) identify and summarize the existing clinical and cohort studies assessing paclitaxel-coated DCBs and DESs, (2) describe and determine the quality of the available data sources for the evaluation of these devices, and (3) present methodologies that can be leveraged for proper signal discernment within available data sources.

Methods

Studies and data sources were identified through comprehensive searches. original research studies, clinical trials, comparative studies, multicenter studies, and observational cohort studies written in the English language and published from January 2007 to November 2021, with a follow-up longer than 36 months, were included in the review. Data quality of available data sources identified was assessed in three groupings. Moreover, accepted data-driven methodologies that may help circumvent the limitations of the extracted studies and data sources were extracted and described.

Results

There were 39 studies and data sources identified. This included 19 randomized clinical trials, nine single-arm studies, eight registries, three administrative claims, and electronic health records. Methodologies focusing on the use of existing premarket clinical data, the incorporation of all contributed patient time, the use of aggregated data, approaches for individual-level data, machine learning and artificial intelligence approaches, Bayesian approaches, and the combination of various datasets were summarized.

Conclusion

Despite the multitude of available studies over the course of eleven years following the first clinical trial, the FDA-convened advisory panel found them insufficient for comprehensively assessing the late-mortality signal. High-quality data sources with the capabilities of employing advanced statistical methodologies are needed to detect potential safety signals in a timely manner and allow regulatory bodies to act quickly when a safety signal is detected.

Evidence-based objective performance criteria for the evaluation of hip and knee replacement devices and technologies

BACKGROUND

Objective performance criteria (OPC) is a novel method to provide minimum performance standards and improve the regulated introduction of original or incremental device innovations in order to prevent patients from being exposed to potentially inferior designs whilst allowing timely access to improvements. We developed 2-year safety and effectiveness OPC for total hip and knee replacement (THR and TKR).

METHODS

Analyses of large databases were conducted using various data sources: a systematic literature review; a direct data analysis from The Functional Outcomes Research for Comparative Effectiveness in Total Joint Replacement and Quality Improvement Registry (FORCE-TJR) and the Kaiser Permanente Implant Registry (KPIR); and claims data analyses from longitudinal discharge data in New York and California states. The literature review included U.S. patients (≥18 years) who received THR or TKR for primary end-stage osteoarthritis and prospectively collected data on patient-reported outcome measures (PROMs) from at least 100 subjects and/or 2-year implant survival for at least 250 implants. Random effects models were used for meta-analysis.

RESULTS

Data were available from a total of 951 100 patients. After screening of 7979 abstracts, 294 studies underwent full-text review and 31 studies contributed to the evidence synthesis (333 995 implants). Direct data analysis of FORCE-TJR contributed 9223 joint replacement patients to the construction of OPC for effectiveness; KPIR contributed 262 044 patients for the construction of OPC for safety. Claims database analysis contributed 345 838 patients to the construction of safety OPC. OPC for safety were constructed for cumulative incidences of 2-year all-cause and septic revision (THR/TKR 2.0%/1.6% and 0.6%/0.7%), and OPC for effectiveness were constructed based on four disease-specific and three general health-related quality of life PROMs (HOOS/KOOS 87.1/80.6; HSS/KSS function 94.4/90.6; SF-12/SF-36, PCS 46.5/41.9, EQ-5D 0.88/0.84).

CONCLUSION

This study is the first to construct a 2-year OPC for the safety and effectiveness of THR and TKR based on U.S. real-world data. Based on these OPC, potential benchmarks for (single-arm study) evaluation of new device innovations are suggested for a regulated and safe introduction to the (commercial) market.

Association of Sex With Risk of 2-Year Revision Among Patients Undergoing Total Hip Arthroplasty

IMPORTANCE

The worldwide population is aging and includes more female individuals than male individuals, with higher rates of total hip arthroplasty (THA) among female individuals. Although research on this topic has been limited to date, several studies are currently under way.

OBJECTIVES

To evaluate the association between sex and 2-year revision after THA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from statewide databases in New York and California between October 1, 2015, and December 31, 2018. Patients 18 years or older with osteoarthritis who underwent THA and had sex recorded in the database were included in the analysis.

EXPOSURE

Total hip arthroplasty.

MAIN OUTCOMES AND MEASURES

The outcome of interest was the difference in early, all-cause revision surgery rates after primary THA between women and men. The association of sex with the revision rate was examined using Cox proportional hazards regression analysis.

RESULTS

Of 132 826 patients included in the study, 74 002 (55.7%) were women; the mean (SD) age was 65.9 (11.0) years, and the median follow-up time was 1.3 years (range, 0.0-3.0 years). The 2-year revision rate was 2.5% (95% CI, 2.4%-2.6%) among women and 2.1% (95% CI, 2.0%-2.2%) among men. After adjusting for demographic characteristics, comorbidities, and facility volume, a minimal clinically meaningful difference was observed in revision rates despite women having a higher risk of all-cause revision compared with men (hazard ratio, 1.16; 95% CI, 1.07-1.26; P < .001). The risk of revision was increased among women compared with men in the subgroup of patients who were younger than 55 years (hazard ratio, 1.47; 95% CI, 1.20-1.81; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, no clinically meaningful difference in all-cause revision rates after primary THA was found between men and women at 2-year follow-up. The modest difference in the risk of revision between men and women in a small subgroup of patients younger than 55 years suggests that the risk of revision in this population should be studied further.

Retinoic acid stimulates immature lung fibroblast growth via a PDGF-mediated autocrine mechanism

All trans-retinoic acid (RA) enhances alveolarization in neonates and reinitiates alveolarization in emphysematous adult rat lungs, suggesting that RA may stimulate cell proliferation by upregulating growth factor ligand and/or receptor expression either indirectly or directly by acting on RA-responsive genes encoding growth factors. We report that RA and 1,25-dihydroxyvitamin D(3) (Vit D), alone and in combination, significantly increase [(3)H]thymidine incorporation in cultured fetal and postnatal rat lung fibroblasts (P < 0.05). The greatest increase (11-fold) was seen in 4-day cells treated with the two agents in combination (P < 0.0001). [(3)H]thymidine incorporation was age dependent. The greatest response to RA occurred in 4-day fibroblasts (P < 0.01), whereas the response to Vit D was greatest in embryonic day 20 fibroblasts (P < 0.001). Neutralizing antibody to platelet-derived growth factor (PDGF)-AB decreased [(3)H]thymidine incorporation in response to RA alone or in combination with Vit D, indicating a role for PDGF. Expression of mRNAs for PDGF-A and PDGF receptor (PDGFR)-alpha and -beta was upregulated at the transcriptional level in an age- and treatment-dependent manner. Thus exogenous RA may influence alveolarization by stimulating fibroblast proliferation through a PDGF-mediated autocrine mechanism, which is enhanced when RA and Vit D are administered in combination.

Dacryocystography: the technique and its role in the practice of ophthalmology

Modern lacrimal tract imaging has most recently been enhanced by computerized digital subtraction techniques. Current standard dacryocystography technique includes the injection of a water-soluble agent and the use of topical anesthesia. In this article the dacryocystogram of the normal lacrimal system and those with various types of obstruction are presented.

Growing intracranial aneurysms

Cerebral angiography is the best means by which an intracranial aneurysm can be demonstrated and studied in vivo. In 16 cases clinical deterioration paralleled a variable degree of enlargement of the aneurysms. In all patients the aneurysms were irregular and/or bior multilocular. Possible factors causing aneurysmal enlargement are discussed.

Cerebral angiographic changes associated with tuberous sclerosis

Two patients with tuberous sclerosis were examined angiographically. In one, direct left carotid angiography showed a contralateral shift of the anterior cerebral artery and lateral displacement of the middle cerebral artery. On the lateral series, increase in the sweep of the anterior cerebral artery as well as stretching of the opercular branches of the middle cerebral artery were noted in the early arterial phase. In the later arterial phase, there was marked hypervascularity, with the contrast substance temporarily pooling in small, rounded collections. In the mid-arterial phase of the second case, pooling of the the contrast medium within the tumor and many small, berry-like outpunchings were noted. There was no evidence of early venous drainage in either case.

The moving embolus seed during serial cerebral angiography

Movement of an occlusive process in an angiographical study is diagnostic of embolization.

Two cases are reported in which the demonstration of a moving embolism on serial angiography is shown.