What Is the Most Appropriate Comparator to Use in Assessing the Comparative Performance of Primary Total Knee Prostheses? A Registry-Based Study

Background

The Australian Orthopedic Association National Joint Replacement Registry has developed a standardized multi-stage approach to identify prostheses with a higher-than-anticipated rate of revision when comparing a prosthesis of interest to all other prostheses within the same broad class. However, the approach does not adequately differentiate between the conventional and complex design prostheses, and the comparator classes need to be re-evaluated. This study aimed to identify a more relevant comparator to better reflect conventional and complex surgical practices according to the stability design and also explore how the rate of revision estimated in the comparator groups affects the identification of "prosthesis outliers."

Methods

The cumulative percent revision (CPR) was calculated for 640,045 primary total knee replacements (TKRs) undertaken for Osteoarthritis from 1 January 2003 to 31 December 2019. At first, survivorship analyses were undertaken to calculate the rate of revision for primary TKR by stability design. A modified TKR comparator group was developed by excluding the "complex" group of prostheses with fully stabilized and hinged designs. The effectiveness of the modified comparator groups, including cruciate retaining and posterior stabilized designs, was evaluated based on the ability to detect additional prostheses by performing the Australian Orthopedic Association National Joint Replacement Registry standardized method for identifying prosthesis outliers.

Results

The modified comparator to include only conventional designs had a 10-year CPR of 5.2% (5.1, 5.3). When the fully stabilized and hinged design groups were combined as a comparator group of complex devices to reflect devices used only for specific purposes in primary TKR, the CPR at 10 year was 10.3% (8.6, 12.0).

Conclusions

The use of modified comparator groups led to identifying additional conventional prostheses but fewer complex designs as being at risk and has the potential to improve the early assessment of TKR prostheses.

What is the most appropriate comparator group to use in assessing the performance of primary total hip prostheses within the community?

BACKGROUND

There are variations in the performance of individual prostheses used in hip replacements. Some of which have unexpectedly higher revision rates - outliers. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) has established a standardised multi-stage approach for identifying these devices. This is done by comparing the revision rates of individual prostheses to all other prostheses in class, with the exception of large head metal-on-metal (LHMoM) prostheses. However, improvements in device design and performance over time have required a need to reconsider the comparator group. This study aimed to identify a more specific comparator to better reflect contemporary surgical practice.

METHODS

The time to first revision was estimated on the data of 413,417 primary total conventional hip replacements undertaken for osteoarthritis (OA) from 01 January 2003 to 31 December 2019. Survivorship analyses with stepwise exclusions were undertaken. The first exclusion was LHMoM, followed by other non-modern bearing surfaces (defined as all the bearing couples except metal or ceramic heads on cross-linked polyethylene and mixed ceramic-on-ceramic), and then devices with modular neck-stem design or used for specific purposes (incl. constrained, dual-mobility, and head size <28 mm). Lastly, all remaining prostheses previously identified as having a higher than anticipated rate of revision (HTARR) were also excluded.

RESULTS

These exclusions progressively reduced the cumulative percent revision (CPR) rate. The final comparator, which only includes satisfactory-performed prostheses of contemporary design and use, has a 10-year CPR of 4.30% (95% CI, 4.2-4.41) which is lower than 4.93% (95% CI, 4.84-5.02) for the current comparator used by the AOANJRR (all prostheses excluding LHMOM). Over the study period, 13 additional components were identified utilising the modified comparator.

CONCLUSIONS

The calculation of the comparator revision rate should be re-evaluated to include only modern prosthesis constructs to ensure that poorly performing prostheses are identified early.

Comparative effectiveness of different placebos and comparator groups for hand osteoarthritis exploring the impact of contextual factors: A systematic review and meta-analysis of randomised trials

OBJECTIVE

To examine the pain relief effects of comparators (placebos and untreated control groups) in hand osteoarthritis trials and the impact of contextual factors.

METHODS

We systematically searched PubMed, EMBASE and CENTRAL from inception to December 26, 2021. We included randomised controlled trials of people with hand osteoarthritis with a placebo or an untreated control group. We assessed the Risk of Bias with Cochrane Risk-of-Bias tool version 2. Each comparator was contrasted with a null-arm, imputed as having a zero change from baseline with the same standard deviation as the comparator. We combined the standardised mean differences with a random effects meta-analysis. The contextual factors' effect was explored in meta-regression and stratified models with pain as the dependent variable.

RESULTS

84 trials (7262 participants) were eligible for quantitative synthesis, of which 76 (6462 participants) were eligible for the stratified analyses. Placebos were superior to their matched null-arms in relieving pain with an effect size of -0.51 (95% confidence interval -0.61 to -0.42), while untreated control groups were not. When analysing all comparators, blinded trial designs and low risk of bias were associated with higher pain relief compared to an open-label trial design and some concern or high risk of bias.

CONCLUSION

The placebo response on pain for people with hand osteoarthritis was increased by appropriate blinding and a lower risk of bias assessment. Placebos were superior to a null-arm, while untreated control groups were not. Results emphasise the importance of using appropriate comparators in clinical trials.

PROSPERO REGISTRATION ID

CRD42022298984.

Re-examining baseline lung function recovery following IV-treated pulmonary exacerbations

CF registry pulmonary exacerbation (PEx) analyses have employed "before and after" spirometry recovery, where the best percent predicted forced expiratory volume in 1 s (ppFEV1) prior to PEx ("baseline") is compared to the best ppFEV1 <3 months post-PEx. This methodology lacks comparators and ascribes recovery failure to PEx. Herein, we describe 2014 CF Foundation Patient Registry PEx analyses including a comparator: recovery around nonPEx events, birthdays. 49.6% of 7357 individuals with PEx achieved baseline ppFEV1 recovery while 36.6% of 14,141 achieved baseline recovery after birthdays; individuals with both PEx and birthdays were more likely to recover baseline after PEx than after birthdays (47% versus 34%); mean ppFEV1 declines were 0.3 (SD=9.3) and 3.1 (9.3), respectively. Post-event measure number had more effect on baseline recovery than did real ppFEV1 loss in simulations, suggesting that PEx recovery analyses lacking comparators are prone to artifact and poorly describe PEx contributions to disease progression.

Gaps in the evidence underpinning high-risk medical devices in Europe at market entry, and potential solutions

AIM

To determine the level of evidence for innovative high-risk medical devices at market entry.

METHODS

We reviewed all Belgian healthcare payer (RIZIV-INAMI) assessor reports on novel implants or invasive medical devices (n = 18, Class IIb-III) available between 2018 to mid-2019 on applications submitted for inclusion on their reimbursement list. We also conducted a review of the literature on evidence gaps and an analysis of relevant legal and ethical frameworks within the European context.

FINDINGS

Conformity assessment of medical devices is based on performance, safety, and an acceptable risk-benefit balance. Information submitted for obtaining CE marking is confidential and legally protected, limiting access to clinical evidence. Seven out of the 18 RIZIV-INAMI assessor reports (39%) included a randomized controlled trial (RCT) using the novel device, whilst 2 applications (11%) referred to an RCT that used a different device. The population included was inappropriate or unclear for 3 devices (17%). Only half of the applications presented evidence on quality of life or functioning and 2 (11%) presented overall survival data. Four applications (22%) included no data beyond twelve months. The findings from the literature demonstrated similar problems with the study design and the clinical evidence.

DISCUSSION AND CONCLUSIONS

CE marking does not indicate that a device is effective, only that it complies with the law. The lack of transparency hampers evidence-based decision making. Despite greater emphasis on clinical benefit for the patient, the provisions of the European Medical Device Regulation (MDR) are not yet fully aligned with international ethical standards for clinical research. The MDR fails to address key issues, such as the lack of access to data submitted for CE marking and a failure to require evidence of clinical effectiveness. Indeed, a first report shows no improvement in the clinical evidence for implantable devices generated under the MDR. Thus, patients may continue to be exposed to ineffective or unsafe novel devices. The Health Technology Assessment Regulation plans for Joint Scientific Consultations for specific high-risk devices before companies begin their pivotal clinical investigations. The demanded comparative evidence should facilitate payer decisions. Nevertheless, there is also a need for legislation requiring comparative RCTs assessing patient-relevant outcomes for high-risk devices to ensure implementation, including development and implementation of common specifications for study designs.

High prevalence of sternal foramina in indigenous Bolivians compared to Midwest Americans and indigenous North Americans (sternal foramina in indigenous Bolivians)

The sternal foramen, usually an asymptomatic osteological defect, can lead to catastrophic consequences if not recognized prior to certain medical procedures. This study reports the prevalence of a sternal foramen in two South Amerindian populations compared with other published populations. We evaluated the presence of sternal foramina using thoracic computed tomography scans of 1334 (48% female) participants from two indigenous populations of Bolivia (n = 900 Tsimane, 434 Moseten). The prevalence of sternal foramina was compared to two U.S. populations of similar sex/age distribution (n = 572 Midwest Americans, 131 self-identified Native North Americans) via similar CT scans. A sternal foramen was significantly more common in the two Bolivian populations (prevalence ranging from 12.8 to 13.4%), compared to 4.4-5.1% in the two U.S. groups, consistent with prior estimates in studies from industrialized populations. Males had higher frequency of a sternal foramen compared to females in each of the four groups (OR = 1.904, 95% CI: 1.418-2.568, p < 0.001). Age was not associated with sternal foramen presence. These data show both a higher rate of sternal foramina in the South Amerindian populations versus comparator populations in North America and the highest rate of any studied living population. Although it is not possible to determine from our data the relative contribution of genetics versus early life or environmental causes to the higher rates of sternal foramen, we note that small prior studies have likewise demonstrated a higher prevalence in lower income countries. Further determination of the contributing factors warrants greater investigation and research.

Some reflections on the use of inappropriate comparators in CEA

Although the choice of the comparator is one of the aspects with a highest effect on the results of cost-effectiveness analyses, it is one of the less debated issues in international methodological guidelines. The inclusion of an inappropriate comparator may introduce biases on the outcomes and the recommendations of an economic analysis. Although the rules for cost-effectiveness analyses of sets of mutually exclusive alternatives have been widely described in the literature, in practice, they are hardly ever applied. In addition, there are many cases where the efficiency of the standard of care has never been assessed; or where the standard of care has demonstrated to be cost-effective with respect to a non-efficient option. In all these cases the comparator may lie outside the efficiency frontier, so the result of the CEA may be biased. Through some hypothetical examples, the paper shows how the complementary use of an independent reference may help to identify potential inappropriate comparators and inefficient use of resources.

Suggestions for improving the design of clinical trials in multiple sclerosis-results of a systematic analysis of completed phase III trials

This manuscript reviews the primary and secondary endpoints of pivotal phase III trials with immunomodulatory drugs in multiple sclerosis (MS). Considering the limitations of previous trial designs, we propose new standards for the planning of clinical trials, taking into account latest insights into MS pathophysiology and patient-relevant aspects. Using a systematic overview of published phase III (pivotal) trials performed as part of application for drug market approval, we evaluate the following characteristics: trial duration, number of trial participants, comparators, and endpoints (primary, secondary, magnetic resonance imaging outcome, and patient-reported outcomes). From a patient perspective, the primary and secondary endpoints of clinical trials are only partially relevant. High-quality trial data pertaining to efficacy and safety that stretch beyond the time frame of pivotal trials are almost non-existent. Understanding of long-term benefits and risks of disease-modifying MS therapy is largely lacking. Concrete proposals for the trial designs of relapsing (remitting) multiple sclerosis/clinically isolated syndrome, primary progressive multiple sclerosis, and secondary progressive multiple sclerosis (e.g., study duration, mechanism of action, and choice of endpoints) are presented based on the results of the systematic overview. Given the increasing number of available immunotherapies, the therapeutic strategy in MS has shifted from a mere “relapse-prevention” approach to a personalized provision of medical care as to the choice of the appropriate drugs and their sequential application over the course of the disease. This personalized provision takes patient preferences as well as disease-related factors into consideration such as objective clinical and radiographic findings but also very burdensome symptoms such as fatigue, depression, and cognitive impairment. Future trial designs in MS will have to assign higher relevance to these patient-reported outcomes and will also have to implement surrogate measures that can serve as predictive markers for individual treatment response to new and investigational immunotherapies. This is an indispensable prerequisite to maximize the benefit of individual patients when participating in clinical trials. Moreover, such appropriate trial designs and suitable enrolment criteria that correspond to the mode of action of the study drug will facilitate targeted prevention of adverse events, thus mitigating risks for individual study participants.

Prediction error and regularity detection underlie two dissociable mechanisms for computing the sense of agency

The sense of agency refers to the subjective feeling of controlling one's own actions, and through them, events in the outside world. According to computational motor control models, the prediction errors from comparison between the predicted sensory feedback and actual sensory feedback determine whether people feel agency over the corresponding outcome event, or not. This mechanism requires a model of the relation between action and outcome. However, in a novel environment, where this model has not yet been learned, the sense of agency must emerge during exploratory behaviours. In the present study, we designed a novel control detection task, in which participants explored the extent to which they could control the movement of three dots with a computer mouse, and then identified the dot that they felt they could control. Pre-recorded motions were applied for two dots, and the participants' real-time motion only influenced one dot's motion (i.e. the target dot). We disturbed participants' control over the motion of the target dot in one of two ways. In one case, we applied a fixed angular bias transformation between participant's movements and dot movements. In another condition, we mixed the participant's current movement with replay of another movement, and used the resulting hybrid signal to drive visual dot position. The former intervention changes the match between motor action and visual outcome, but maintains a regular relation between the two. In contrast, the latter alters both matching and motor-visual correlation. Crucially, we carefully selected the strength of these two perturbations so that they caused the same magnitude of impairment of motor performance in a simple reaching task, suggesting that both interventions produced comparable prediction errors. However, we found the visuomotor transformation had much less effect on the ability to detect which dot was under one's own control than did the nonlinear disturbance. This suggests a specific role of a correlation-like mechanism that detects ongoing visual-motor regularity in the human sense of agency. These regularity-detection mechanisms would remain intact under the linear, but not the nonlinear transformation. Human sense of agency may depend on monitoring ongoing motor-visual regularities, as well as on detecting prediction errors.

The role of the temporoparietal junction in implicit and explicit sense of agency

The experience of being in control of one's actions and thier outcomes is called the sense of agency. This is a fundamental feature of our human experience, and may underpin important social functions such as morality and responsibility. Sense of agency can be measured explicitly, by asking people to report their experience, or implicitly by recording the perceived time interval between actions and outcomes (intentional binding). The current studies used transcranial direct current stimulation to assess the role of left and right temporoparietal junction in both implicit and explicit sense of agency. Participants were informed that they could control the volume output of the computer with one of two buttons. Participants experienced reduced sense of agency when the outcome was inconsistent with their action. However, binding did not differ between congruent and incongruent action-outcomes. The modulation of explicit agency ratings by action-outcome congruency was significantly reduced by right TPJ stimulation (experiment 1) but not left TPJ stimulation (experiment 2). Implicit agency was not affected in either stimulation condition. These findings are discussed in terms of the possible neural mechanisms of implicit and explicit sense of agency.

An Ultra-Low Power Charge Redistribution Successive Approximation Register A/D Converter for Biomedical Applications

Power consumption is one of the key design constraints in biomedical devices such as pacemakers that are powered by small non rechargeable batteries over their entire life time. In these systems, Analog to Digital Convertors (ADCs) are used as interface between analog world and digital domain and play a key role. In this paper we present the design of an 8-bit Charge Redistribution Successive Approximation Register (CR-SAR) analog to digital converter in standard TSMC 0.18μm CMOS technology for low power and low data rate devices such as pacemakers. The 8-bit optimized CR-SAR ADC achieves low power of less than 250nW with conversion rate of 1KB/s. This ADC achieves integral nonlinearity (INL) and differential nonlinearity (DNL) less than 0.22 least significant bit (LSB) and less than 0.04 LSB respectively as compared to the standard requirement for the INL and DNL errors to be less than 0.5 LSB. The designed ADC operates at 1V supply voltage converting input ranging from 0V to 250mV.

Control feedback as the motivational force behind habitual behavior

Motivated behavior is considered to be a product of integration of a behavior's subjective benefits and costs. As such, it is unclear what motivates "habitual behavior" which occurs, by definition, after the outcome's value has diminished. One possible answer is that habitual behavior continues to be selected due to its "intrinsic" worth. Such an explanation, however, highlights the need to specify the motivational system for which the behavior has intrinsic worth. Another key question is how does an activity attain such intrinsically rewarding properties. In an attempt to answer both questions, we suggest that habitual behavior is motivated by the influence it brings over the environment-by the control motivation system, including "control feedback." Thus, when referring to intrinsic worth, we refer to a representation of an activity that has been reinforced due to it being effective in controlling the environment, managing to make something happen. As an answer to when does an activity attain such rewarding properties, we propose that this occurs when the estimated instrumental outcome expectancy of an activity is positive, but the precision of this expectancy is low. This lack of precision overcomes the chronic dominance of outcome feedback over control feedback in determining action selection by increasing the relative weight of the control feedback. Such a state of affairs will lead to repeated selection of control relevant behavior and entails insensitivity to outcome devaluation, thereby producing a habit.

Implementation of AMNOG: An industry perspective

In 2010, the Federal Parliament (Bundestag) of Germany passed a new law (Arzneimittelmarktneuordnungsgesetz, AMNOG) on the regulation of medicinal products that applies to all pharmaceutical products with active ingredients that are launched beginning January 1, 2011. The law describes the process to determine the price at which an approved new product will be reimbursed by the statutory health insurance system. The process consists of two phases. The first phase assesses the additional benefit of the new product versus an appropriate comparator (zweckmäßige Vergleichstherapie, zVT). The second phase involves price negotiation. Focusing on the first phase, this paper investigates requirements of benefit assessment of a new product under this law with special attention on the methods applied by the German authorities on issues such as the choice of the comparator, patient relevant endpoints, subgroup analyses, extent of benefit, determination of net benefit, primary and secondary endpoints, and uncertainty of the additional benefit. We propose alternative approaches to address the requirements in some cases and invite other researchers to help develop solutions in other cases.

Neurofunctional model of large-scale correlates of selective attention governed by stimulus-novelty

Multiple studies demonstrate the influence of the limbic system on the processing of sensory events and attentional guidance. But the mechanisms involved therein are yet not entirely clear. The close connection of handling incoming sensory information and memory retrieval, like in the case of habituation towards insignificant stimuli, suggests a crucial impact of the hippocampus on the direction of attention. In this paper we thus present a neurofunctional forward model of a hippocampal comparator function based on the theory of theta-regulated attention. Subsequently we integrated this comparator model into a multiscale framework for the simulation of evoked responses. The results of our simulations were compared to experimental data on electroencephalographic (EEG) correlates of habituation towards familiar stimuli using time-scale analysis. In consequence we are able to present additional evidence for limbic influences on the direction of attention driven by stimulus novelty and a systems neuroscience framework for the statements given in the theta-regulated attention hypothesis.

The International Practical Temperature Scale of 1968 in the Region 90.188 K to 903.89 K as Maintained at the National Bureau of Standards

The reproducibility of the International Practical Temperature Scale of 1968 (IPTS-68) in the region 90.188 K to 903.89 K as maintained at the National Bureau of Standards is discussed. The realizations of the triple point of water, the freezing points of zinc and tin, and the boiling point of oxygen are described. The average of the standard deviations of the resistance measurements at the triple point of water of 213 platinum resistance thermometers received for calibration over a two-year period corresponds to ±0.15 mK. The standard deviations of the resistance ratio R(T)/R(0°C) obtained with check thermometers employed for monitoring the zinc, tin, and oxygen point measurements correspond to ±0.28 mK, ±0.30 mK, and ±0.16 mK, respectively; the results of repeated calibrations with five thermometers show comparable reproducibility at the tin and oxygen points but the reproducibility is worse by a factor of two at the zinc point. When suitably packed for protection from possible mechanical shock platinum resistance thermometers can be shipped by common carrier and retain their calibrations.