Mechanical performance of lumbar intervertebral body fusion devices: An analysis of data submitted to the Food and Drug Administration

Lumbar intervertebral body fusion devices (L-IBFDs) are intended to provide stability to promote fusion in patients with a variety of lumbar pathologies. Different L-IBFD designs have been developed to accommodate various surgical approaches for lumbar interbody fusion procedures including anterior, lateral, posterior, and transforaminal lumbar interbody fusions (ALIF, LLIF, PLIF, and TLIF, respectively). Due to design differences, there is a potential for mechanical performance differences between ALIF, LLIF, PLIF, and TLIF devices. To evaluate this, mechanical performance and device dimension data were collected from 124 Traditional 510(k) submissions to the FDA for L-IBFDs cleared for marketing from 2007 through 2016. From these submissions, mechanical test results were aggregated for seven commonly performed tests: static and dynamic axial compression, compression-shear, and torsion testing per ASTM F2077, and subsidence testing per ASTM F2267. The Kruskal-Wallis test and Wilcoxon signed-rank test were used to determine if device type (ALIF, LLIF, PLIF, TLIF) had a significant effect on mechanical performance parameters (static testing: stiffness and yield strength; dynamic testing: runout load; subsidence testing: stiffness [Kp]). Generally, ALIFs and LLIFs were found to be stiffer, stronger, and had higher subsidence resistance than PLIF and TLIF designs. These results are likely due to the larger footprints of the ALIF and LLIF devices. The relative mechanical performance and subsidence resistance can be considered when determining the appropriate surgical approach and implant for a given patient. Overall, the mechanical performance data presented here can be utilized for future L-IBFD development and design verification.     

Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration

Background

Meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment, and when unpublished trial data are included, the benefit falls below accepted criteria for clinical significance. Yet, the efficacy of the antidepressants may also depend on the severity of initial depression scores. The purpose of this analysis is to establish the relation of baseline severity and antidepressant efficacy using a relevant dataset of published and unpublished clinical trials.

Methods and Findings

We obtained data on all clinical trials submitted to the US Food and Drug Administration (FDA) for the licensing of the four new-generation antidepressants for which full datasets were available. We then used meta-analytic techniques to assess linear and quadratic effects of initial severity on improvement scores for drug and placebo groups and on drug–placebo difference scores. Drug–placebo differences increased as a function of initial severity, rising from virtually no difference at moderate levels of initial depression to a relatively small difference for patients with very severe depression, reaching conventional criteria for clinical significance only for patients at the upper end of the very severely depressed category. Meta-regression analyses indicated that the relation of baseline severity and improvement was curvilinear in drug groups and showed a strong, negative linear component in placebo groups.

Conclusions

Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.     

Reporting Bias in Drug Trials Submitted to the Food and Drug Administration: Review of Publication and Presentation

Background

Previous studies of drug trials submitted to regulatory authorities have documented selective reporting of both entire trials and favorable results. The objective of this study is to determine the publication rate of efficacy trials submitted to the Food and Drug Administration (FDA) in approved New Drug Applications (NDAs) and to compare the trial characteristics as reported by the FDA with those reported in publications.

Methods and Findings

This is an observational study of all efficacy trials found in approved NDAs for New Molecular Entities (NMEs) from 2001 to 2002 inclusive and all published clinical trials corresponding to the trials within the NDAs. For each trial included in the NDA, we assessed its publication status, primary outcome(s) reported and their statistical significance, and conclusions. Seventy-eight percent (128/164) of efficacy trials contained in FDA reviews of NDAs were published. In a multivariate model, trials with favorable primary outcomes (OR = 4.7, 95% confidence interval [CI] 1.33–17.1, p = 0.018) and active controls (OR = 3.4, 95% CI 1.02–11.2, p = 0.047) were more likely to be published. Forty-one primary outcomes from the NDAs were omitted from the papers. Papers included 155 outcomes that were in the NDAs, 15 additional outcomes that favored the test drug, and two other neutral or unknown additional outcomes. Excluding outcomes with unknown significance, there were 43 outcomes in the NDAs that did not favor the NDA drug. Of these, 20 (47%) were not included in the papers. The statistical significance of five of the remaining 23 outcomes (22%) changed between the NDA and the paper, with four changing to favor the test drug in the paper (p = 0.38). Excluding unknowns, 99 conclusions were provided in both NDAs and papers, nine conclusions (9%) changed from the FDA review of the NDA to the paper, and all nine did so to favor the test drug (100%, 95% CI 72%–100%, p = 0.0039).

Conclusions

Many trials were still not published 5 y after FDA approval. Discrepancies between the trial information reviewed by the FDA and information found in published trials tended to lead to more favorable presentations of the NDA drugs in the publications. Thus, the information that is readily available in the scientific literature to health care professionals is incomplete and potentially biased.     

Sensitivity of MRI signal distribution within the intervertebral disc to image segmentation and data normalisation

There is a lack of early biomarkers of intervertebral disc (IVD) degeneration. Thus, the authors developed the analysis of magnetic resonance signal intensity distribution (AMRSID) method to analyse the 3D distribution of the T2-weighted MR signal intensity within the IVD using normalised histograms, weighted centres and volume ratios. The objective was to assess the sensitivity of the AMRSID method to the segmentation process and data normalisation. Repetition of the semi-automatic segmentation by the same operator did not influence the quality of the contour or our new MR distribution parameters whereas the skills of the operator influenced only the MR distribution parameters, and the instructions given prior to the segmentation influenced both the quality of the contour and the MR distribution parameters. Bone normalisation produces an index that jointly highlights IVD and bone health, whereas cerebrospinal fluid normalisation only suppresses the effect of the acquisition gain. This robust AMRSID method has the potential to improve the diagnostic with earlier biomarkers and the prognosis of evolution.     

Therapeutic effects of whole‐body devices applying pulsed electromagnetic fields (PEMF): A systematic literature review

Pulsed electromagnetic fields (PEMF) delivered by whole‐body mats are promoted in many countries for a wide range of therapeutic applications and for enhanced well‐being. However, neither the therapeutic efficacy nor the potential health hazards caused by these mats have been systematically evaluated. We conducted a systematic review of trials investigating the therapeutic effects of low‐frequency PEMF devices. We were interested in all health outcomes addressed so far in randomized, sham‐controlled, double‐blind trials. In total, 11 trials were identified. They were focused on osteoarthritis of the knee (3 trials) or the cervical spine (1), fibromyalgia (1), pain perception (2), skin ulcer healing (1), multiple sclerosis‐related fatigue (2), or heart rate variability and well‐being (1). The sample sizes of the trials ranged from 12 to 71 individuals. The observation period lasted 12 weeks at maximum, and the applied magnetic flux densities ranged from 3.4 to 200 µT. In some trials sporadic positive effects on health were observed. However, independent confirmation of such singular findings was lacking. We conclude that the scientific evidence for therapeutic effects of whole‐body PEMF devices is insufficient. Acute adverse effects have not been reported. However, adverse effects occurring after long‐term application have not been studied so far. In summary, the therapeutic use of low‐frequency whole‐body PEMF devices cannot be recommended without more scientific evidence from high‐quality, double‐blind trials. Bioelectromagnetics 33:95–105, 2012. © 2011 Wiley Periodicals, Inc.     

Hospitalization outcomes and racial disparities in cervical cancer patients: An analysis of the national inpatient sample data from 2002 to 2014

BackgroundLittle is known about outcomes in patients after being hospitalized for care of cancer or comorbid conditions and the disparity between African-American and White cervical cancer patients.MethodsUsing the national inpatient sample (HCUP-NIS) database of the Healthcare Cost and Utilization Project between 2002–2014, we included 5217 African-American and 21,752 White patients hospitalized with a primary diagnosis of cervical cancer. We examined racial differences in hospitalization outcomes; length of stay (LOS) in hospital, mortality in hospital, post-operative complications in patients who underwent hysterectomy and discharge disposition. Patients were matched on age at primary diagnosis, insurance status, residential region, and median income of residential area, modified Deyo comorbidity index, stage of disease and treatment. Categorical outcomes were analyzed by conditional logistic regression accounting for matched study design and odds ratios (95%CI) were reported. LOS was analyzed using t-test and beta estimate for difference in means was reported.ResultsThe LOS was significantly lower for Whites compared to African-American cervical cancer patients when matched on demographic only (β=-0.41, p-value<0.0005, presentation + demographic (β=-0.41, p-value<0.0006) and treatment + presentation + demographic variables (β=-0.46, p-value<0.0001). White cervical cancer patients were commonly discharged to other intermediate nursing facility (OR = 1.30, 95%CI = 1.20–1.41, matched on demographic only; OR = 1.31, 95%CI = 1.21–1.43, matched on presentation + demographic; and OR = 1.32, 95%CI = 1.22–1.43), matched on treatment + presentation + demographic). Similar trends were seen in both older (≥65 years) and younger (<65 years) patients, when stratified by age.ConclusionDisparities in hospitalization outcomes in cervical patients are not observed when different characteristics of African-American and White cervical patients are accounted for and matched.     

A multipurpose fusion tag derived from an unstructured and hyperacidic region of the amyloid precursor protein

Expression and purification of aggregation‐prone and disulfide‐containing proteins in Escherichia coli remains as a major hurdle for structural and functional analyses of high‐value target proteins. Here, we present a novel gene‐fusion strategy that greatly simplifies purification and refolding procedure at very low cost using a unique hyperacidic module derived from the human amyloid precursor protein. Fusion with this polypeptide (dubbed FATT for Flag‐Acidic‐Target Tag) results in near‐complete soluble expression of variety of extracellular proteins, which can be directly refolded in the crude bacterial lysate and purified in one‐step by anion exchange chromatography. Application of this system enabled preparation of functionally active extracellular enzymes and antibody fragments without the need for condition optimization.     

Superior performance of continuous over pulsatile flow ventricular assist devices in the single ventricle circulation: A computational study

This study compares the physiological responses of systemic-to-pulmonary shunted single ventricle patients to pulsatile and continuous flow ventricular assist devices (VADs). Performance differences between pulsatile and continuous flow VADs have been clinically observed, but the underlying mechanism remains poorly understood. Six systemic-to-pulmonary shunted single ventricle patients (mean BSA=0.30 m²) were computationally simulated using a lumped-parameter network tuned to match patient specific clinical data. A first set of simulations compared current clinical implementation of VADs in single ventricle patients. A second set modified pulsatile flow VAD settings with the goal to optimize cardiac output (CO). For all patients, the best-case continuous flow VAD CO was at least 0.99 L/min greater than the optimized pulsatile flow VAD CO (p=0.001). The 25 and 50 mL pulsatile flow VADs exhibited incomplete filling at higher heart rates that reduced CO as much as 9.7% and 37.3% below expectations respectively. Optimization of pulsatile flow VAD settings did not achieve statistically significant (p<0.05) improvement to CO. Results corroborate clinical experience that continuous flow VADs produce higher CO and superior ventricular unloading in single ventricle patients. Impaired filling leads to performance degradation of pulsatile flow VADs in the single ventricle circulation.     

Mechanics of the right whale mandible: Full scale testing and finite element analysis

In an effort to better understand the mechanics of ship-whale collision and to reduce the associated mortality of the critically endangered North Atlantic right whale, a comprehensive biomechanical study has been conducted by the Woods Hole Oceanographic Institution and the University of New Hampshire. The goal of the study is to develop a numerical modeling tool to predict the forces and stresses during impact and thereby the resulting mortality risk to whales from ship strikes.Based on post-mortem examinations, jaw fracture was chosen as a fatal endpoint for the whales hit by a vessel. In this paper we investigate the overall mechanical behavior of a right whale mandible under transverse loading and develop a finite element analysis model of the bone. The equivalent elastic modulus of the cortical component of right whale mandible is found by comparing full-scale bending tests with the results of numerical modeling. The finite element model of the mandible can be used in conjunction with a vessel-whale collision event model to predict bone fracture for various ship strike scenarios.     

Publication Bias in Antipsychotic Trials: An Analysis of Efficacy Comparing the Published Literature to the US Food and Drug Administration Database

Background

Publication bias compromises the validity of evidence-based medicine, yet a growing body of research shows that this problem is widespread. Efficacy data from drug regulatory agencies, e.g., the US Food and Drug Administration (FDA), can serve as a benchmark or control against which data in journal articles can be checked. Thus one may determine whether publication bias is present and quantify the extent to which it inflates apparent drug efficacy.

Methods and Findings

FDA Drug Approval Packages for eight second-generation antipsychotics—aripiprazole, iloperidone, olanzapine, paliperidone, quetiapine, risperidone, risperidone long-acting injection (risperidone LAI), and ziprasidone—were used to identify a cohort of 24 FDA-registered premarketing trials. The results of these trials according to the FDA were compared with the results conveyed in corresponding journal articles. The relationship between study outcome and publication status was examined, and effect sizes derived from the two data sources were compared. Among the 24 FDA-registered trials, four (17%) were unpublished. Of these, three failed to show that the study drug had a statistical advantage over placebo, and one showed the study drug was statistically inferior to the active comparator. Among the 20 published trials, the five that were not positive, according to the FDA, showed some evidence of outcome reporting bias. However, the association between trial outcome and publication status did not reach statistical significance. Further, the apparent increase in the effect size point estimate due to publication bias was modest (8%) and not statistically significant. On the other hand, the effect size for unpublished trials (0.23, 95% confidence interval 0.07 to 0.39) was less than half that for the published trials (0.47, 95% confidence interval 0.40 to 0.54), a difference that was significant.

Conclusions

The magnitude of publication bias found for antipsychotics was less than that found previously for antidepressants, possibly because antipsychotics demonstrate superiority to placebo more consistently. Without increased access to regulatory agency data, publication bias will continue to blur distinctions between effective and ineffective drugs. Please see later in the article for the Editors'' Summary     

Molecular dynamics simulations of the influenza hemagglutinin fusion peptide in micelles and bilayers: conformational analysis of peptide and lipids

Molecular dynamics simulations of the influenza hemagglutinin fusion peptide in two differently sized dodecylphosphocholine micelles and a palmitoyl oleoyl phosphatidylcholine bilayer were generated to analyze the influence of the environment. Four independent trajectories (5 ns each for the bilayer, and 2 ns each for the micelles) were generated for each system. The peptide lies at the surface of the micelles, while its N-terminal region inserts deeply in the bilayer. This leads to a substantial increase of the solvation and rigidity of the peptide in micelles as compared to the bilayer. The average structures, nevertheless, are similar in all three systems and agree reasonably with micelle-based NMR structures. When in the bilayer, the peptide increases the chain gauche population and area of adjacent lipids in the same binding leaflet, while it has the opposite effect for the nearby lipids of the other leaflet. These changes, which occur spontaneously to fill voids and defects, cause a decrease in the thickness of the membrane in the neighborhood of the peptide. They would be expected to promote positive curvature, as consistent with the formation of the convex bulge, or "nipple", in the initial stage of membrane fusion. An extension of the classical surfactant theory of Israelachvili based on shapes is proposed to introduce the concept of a "dynamically induced shape" of the membrane lipids by the peptide.     

Performing ethnicity: performance,gender, body and belief in the construction and signalling of identity

It is widely accepted that the notions of ‘race’ and ‘ethnicity’ are socially constructed: they refer in other words to culturally shaped conceptions of identity that may or may not have any specific relationship to underlying genetic or visible phenotypical characteristics of the individuals or groups in question. While this has allowed manifestations of racism to be identified for what they are – malignant myths – an over-sociological conception of race and ethnicity can easily overlook other significant, and fluid, forms of identity formation and transformation. This editorial suggests some of these forms and posits ways in which they might inform thinking about race and ethnicity in fresh ways, especially drawing on recent advances in performance theory.     

Construction of a risk model through the fusion of experimental data and finite element modeling: Application to car crash-induced TBI

This article introduces a new approach for the construction of a risk model for the prediction of Traumatic Brain Injury (TBI) as a result of a car crash. The probability of TBI is assessed through the fusion of an experiment-based logistic regression risk model and a finite element (FE) simulation-based risk model. The proposed approach uses a multilevel framework which includes FE simulations of vehicle crashes with dummy and FE simulations of the human brain. The loading conditions derived from the crash simulations are transferred to the brain model thus allowing the calculation of injury metrics such as the Cumulative Strain Damage Measure (CSDM). The framework is used to propagate uncertainties and obtain probabilities of TBI based on the CSDM injury metric. The risk model from FE simulations is constructed from a support vector machine classifier, adaptive sampling, and Monte-Carlo simulations. An approach to compute the total probability of TBI, which combines the FE-based risk assessment as well as the risk prediction from the experiment-based logistic regression model is proposed. In contrast to previous published work, the proposed methodology includes the uncertainty of explicit parameters such as impact conditions (e.g., velocity, impact angle), and material properties of the brain model. This risk model can provide, for instance, the probability of TBI for a given assumed crash impact velocity.     

Trends in incidence of,and mortality from,cervical lesions in Ireland: Baseline data for future evaluation of the national cervical screening programme

AimTo investigate incidence and mortality trends for cervical lesions in Ireland in the period 1994–2008.MethodsWe used data from the National Cancer Registry, Ireland and national death registration data to calculate age-standardised rates for the periods of interest. We used standardised rate ratios to test whether incidence was associated with socio-demographic variables and used Joinpoint to examine trends by morphology grouping.ResultsIncidence of cervical cancer and cervical intraepithelial neoplasia (CIN3) rose over the period 1994–2008. The annual percentage change for cervical cancer was 1.8% and that for CIN3 was 3.8%. Women resident in the most deprived areas had invasive cervical cancer incidence almost twice as high as those resident in the least deprived areas (standardised rate ratio (SRR) = 1.8). Comparing incidence in Ireland to England and Wales, Northern Ireland and Scotland in the three years 2005–2007, the SRRs (other areas vs. Ireland) were 0.70, 0.88 and 0.84 respectively. Cervical cancer rates have fallen in these countries in the same period that there is a rise demonstrated in Ireland.ConclusionIncidence rates of cervical cancer rose in Ireland steadily, albeit modestly, during 1994–2008, most likely due to long-term changes in patterns of sexual behaviour and contraceptive use. A more pronounced rise in CIN3 rates point to considerable levels of opportunistic screening during this period. Mortality rates have changed little over the past four decades, in contrast to trends in countries with well-organised screening programmes.     

A new approach to the molecular analysis of docking, priming, and regulated membrane fusion

Studies using isolated sea urchin cortical vesicles have proven invaluable in dissecting mechanisms of Ca²⁺-triggered membrane fusion. However, only acute molecular manipulations are possible in vitro. Here, using selective pharmacological manipulations of sea urchin eggs ex vivo, we test the hypothesis that specific lipidic components of the membrane matrix selectively affect defined late stages of exocytosis, particularly the Ca²⁺-triggered steps of fast membrane fusion. Egg treatments with cholesterol-lowering drugs resulted in the inhibition of vesicle fusion. Exogenous cholesterol recovered fusion extent and efficiency in cholesterol-depleted membranes; α-tocopherol, a structurally dissimilar curvature analogue, selectively restored fusion extent. Inhibition of phospholipase C reduced vesicle phosphatidylethanolamine and suppressed both the extent and kinetics of fusion. Although phosphatidylinositol-3-kinase inhibition altered levels of polyphosphoinositide species and reduced all fusion parameters, sequestering polyphosphoinositides selectively inhibited fusion kinetics. Thus, cholesterol and phosphatidylethanolamine play direct roles in the fusion pathway, contributing negative curvature. Cholesterol also organizes the physiological fusion site, defining fusion efficiency. A selective influence of phosphatidylethanolamine on fusion kinetics sheds light on the local microdomain structure at the site of docking/fusion. Polyphosphoinositides have modulatory upstream roles in priming: alterations in specific polyphosphoinositides likely represent the terminal priming steps defining fully docked, release-ready vesicles. Thus, this pharmacological approach has the potential to be a robust high-throughput platform to identify molecular components of the physiological fusion machine critical to docking, priming, and triggered fusion.     

Methotrexate-Loaded Chitosan- and Glycolchitosan-Based Nanoparticles: A Promising Strategy for the Administration of the Anticancer Drug to Brain Tumors

Brain tumor treatment employing methotrexate (MTX) is limited by the efflux mechanism of Pg-p on the blood–brain barrier. We aimed to investigate MTX-loaded chitosan or glycol chitosan (GCS) nanoparticles (NPs) in the presence and in the absence of a coating layer of Tween 80 for brain delivery of MTX. The effect of a low Tween 80 concentration was evaluated. MTX NPs were formulated following the ionic gelation technique and size and zeta potential measurements were acquired. Transport across MDCKII-MDR1 monolayer and cytotoxicity studies against C6 glioma cell line were also performed. Cell/particles interaction was visualized by confocal microscopy. The particles were shown to be cytotoxic against C6 cells line and able to overcome MDCKII-MDR1 cell barrier. GCS-based NPs were the most cytotoxic NPs. Confocal observations highlighted the internalization of Tween 80-coated fluorescent NPs more than Tween 80-uncoated NPs. The results suggest that even a low concentration of Tween 80 is sufficient for enhancing the transport of MTX from the NPs across MDCKII-MDR1 cells. The nanocarriers represent a promising strategy for the administration of MTX to brain tumors which merits further investigations under in vivo conditions.