The combination of medical devices and medicinal products revisited from the new European legal framework

Regulatory issues related to the use of sodium hypochlorite solutions in endodontics

AIM

To assess the regulation of sodium hypochlorite (NaOCl) solutions for endodontic usage in some of the world's main dental markets, in view of the European Union's recent move to classify antimicrobial root canal irrigants as high-risk devices under their Medical Device Regulation (MDR).

METHODOLOGY

The authors consulted legal texts available online and communicated with local health authorities wherever necessary to assess into which medical device category NaOCl solutions intended for endodontic application were subsumed. Furthermore, it was investigated whether there were sources outside the dental market to obtain NaOCl solutions for root canal treatments.

RESULTS

Upon completion of this text (mid 2024), NaOCl solutions for root canal irrigation had not been classified in the US and Canada, whilst in the European Union, they had just been upgraded to high-risk medical devices, with all the consequences for the dental supply market. This MDR rule was adopted by the EU's close trading partners, the United Kingdom, Switzerland and Turkey. In Japan, the legal hurdles were already high for manufacturers and importers of endodontic NaOCl solutions. Conversely, in China, these solutions were down-graded from a high-risk to a medium-risk status in 2017. A low-medium risk category was applied in the other countries under investigation, that is, Australia, India and Brazil. In some countries there was a possibility for dentists to procure plain NaOCl solutions from pharmacies. An alternative route to avoid buying NaOCl from dental suppliers was to use (household) bleach solutions for root canal irrigation wherever this practice was not prohibited explicitly.

CONCLUSIONS

The legal situation to produce, import and use NaOCl solutions for root canal irrigation differs vastly around the globe. A sensible approach to regulate (yet not over-regulate) endodontic NaOCl solutions appears to be timely and necessary.

Antibacterial and antifouling materials for urinary catheter coatings

Implantable medical devices have played a significant role in improving both medical care and patients' quality of life. Urinary Catheters (UCs) are commonly utilized as a substitute for bladder drainage and urine collection to prevent urinary retention in patients. However, bacterial colonization and biofilm formation on the catheter surface are prone to occur, leading to catheter-associated urinary tract infections (CAUTIs) and other complications. In recent years, UC coatings have garnered increasing attention. In this review, various antifouling and antibacterial materials for UC coatings are summarized and their impacts on bacterial activities are linked to potential mechanisms of action. Additionally, this review provides an in-depth understanding of the current advancements in UC coatings by presenting the advantages, limitations, notable achievements, and latest research findings. Finally, it anticipates the prospective design and development trajectories of UC coatings in this domain. This holds paramount significance in advancing medical device technology. STATEMENT OF SIGNIFICANCE: Combating catheter-associated urinary tract infections is a major healthcare challenge, and urinary catheter (UC) coatings are considered promising candidates to counter these infections. In this review, various antifouling and antibacterial materials for UCs are summarized, and their impacts on bacterial activities are linked to potential mechanisms of action. Additionally, the review provides an in-depth understanding of the current advancements in UC coatings by presenting the advantages, limitations, notable achievements, and latest research findings. This holds paramount significance in advancing medical device technology. This review not only contributes to the scientific research but also sparks interest among readerships and other researchers in the study of safer and more effective UC coatings for improved patient outcomes.

Latest advances in glucose-responsive microneedle-based systems for transdermal insulin delivery

The development of a self-regulated minimally invasive system for insulin delivery can be considered as the holy grail in the field of diabetes mellitus. A delivery system capable of releasing insulin in response to blood glucose levels would significantly improve the quality of life of diabetic patients, eliminating the need for frequent finger-prick tests and providing better glycaemic control with lower risk of hypoglycaemia. In this context, the latest advances in glucose-responsive microneedle-based transdermal insulin delivery are here compiled with a thorough analysis of the delivery mechanisms and challenges lying ahead in their clinical translation. Two main groups of microneedle-based systems have been developed so far: glucose oxidase-containing and phenylboronic acid-containing systems. Both strategies in combination have also been tested and two other novel strategies are under development, namely electronic closed-loop and glucose transporter-based systems. Results from preclinical studies conducted using these different types of glucose-triggered release systems are comprehensively discussed. Altogether, this analysis from both a mechanistic and translational perspective will provide rationale and/or guidance for future trends in the research hotspot of glucose-responsive microneedle-based insulin delivery systems.

Use of digital health applications for the detection of atrial fibrillation

The advances in health care technologies over the last decade have led to improved capabilities in the use of digital health applications (DiHA) for the detection of atrial fibrillation (AFib). Thus, home-based remote heart rhythm monitoring is facilitated by smartphones or smartwatches alone or combined with external sensors. The available products differ in terms of type of application (wearable vs. handheld) and the technique used for rhythm detection (electrocardiography [ECG] vs. photoplethysmography [PPG]). While ECG-based algorithms often require additional sensors, PPG utilizes techniques integrated in smartphones or smartwatches. Algorithms based on artificial intelligence allow for the automated diagnosis of AFib, enabling high diagnostic accuracy for both ECG-based and PPG-based DiHA. Advantages for clinical use result from the widespread accessibility of rhythm monitoring, thereby permitting earlier diagnosis and higher AFib detection rates. DiHA are also useful for the follow-up of patients with known AFib by monitoring the success of therapeutic interventions to restore sinus rhythm, e.g. catheter ablation. Although some studies strongly suggest a potential benefit for the use of DiHA in the setting of AFib, the overall evidence for an improvement in hard, clinical endpoints and positive effects on clinical care is scarce. To enhance the acceptance of DiHA use in daily practice, more studies evaluating their clinical benefits for the detection of AFib are required. Moreover, most of the applications are still not reimbursable, although the German Digital Health Care Act (Digitale-Versorgung-Gesetz, DVG) made reimbursement possible in principle in 2019.

Digitalized transcranial electrical stimulation: A consensus statement

OBJECTIVE

Although relatively costly and non-scalable, non-invasive neuromodulation interventions are treatment alternatives for neuropsychiatric disorders. The recent developments of highly-deployable transcranial electric stimulation (tES) systems, combined with mobile-Health technologies, could be incorporated in digital trials to overcome methodological barriers and increase equity of access. The study aims are to discuss the implementation of tES digital trials by performing a systematic scoping review and strategic process mapping, evaluate methodological aspects of tES digital trial designs, and provide Delphi-based recommendations for implementing digital trials using tES.

METHODS

We convened 61 highly-productive specialists and contacted 8 tES companies to assess 71 issues related to tES digitalization readiness, and processes, barriers, advantages, and opportunities for implementing tES digital trials. Delphi-based recommendations (>60% agreement) were provided.

RESULTS

The main strengths/opportunities of tES were: (i) non-pharmacological nature (92% of agreement), safety of these techniques (80%), affordability (88%), and potential scalability (78%). As for weaknesses/threats, we listed insufficient supervision (76%) and unclear regulatory status (69%). Many issues related to methodological biases did not reach consensus. Device appraisal showed moderate digitalization readiness, with high safety and potential for trial implementation, but low connectivity.

CONCLUSIONS

Panelists recognized the potential of tES for scalability, generalizability, and leverage of digital trials processes; with no consensus about aspects regarding methodological biases.

SIGNIFICANCE

We further propose and discuss a conceptual framework for exploiting shared aspects between mobile-Health tES technologies with digital trials methodology to drive future efforts for digitizing tES trials.

New In Situ-Generated Polymer-Iodine Complexes with Broad-Spectrum Antimicrobial Activity

Iodine-containing systems show broad antiseptic properties that can be an invaluable tool in controlling infections in humans and animals. Here, we describe the first proof-of-concept studies on biocidal active polyamide- and polyurethane-iodine complexes that are produced in situ directly during the fabrication and/or polymerization process at laboratory and commercially relevant scales. These polymer-iodine materials are active against a broad range of microorganisms, including bacteria and fungi. It is suggested that the ease of manufacture and subsequent commercialization make said systems especially suited for applications as base materials for medical devices to reduce infection risks and control the spread of pathogens. IMPORTANCE Infectious diseases are of mounting medical and public concern. A major contributor to this trend is the proliferation of medical implants, which are inherently vulnerable to microbial contamination and the subsequent onset of hospital-acquired infections. Moreover, implant-associated infections in humans are often difficult to diagnose and treat and are associated with substantial health care costs. Here, we present the development of biocidal active polyamide- and polyurethane-iodine complexes that are generated in situ during fabrication. We show that the excellent antiseptic properties of water-soluble povidone-iodine can be similarly realized in water-insoluble engineering plastics, specifically polyamide- and polyurethane-iodine. These complexes have inherent biocidal activity against major pathogenic bacteria and fungi.

Recent Advances in Antimicrobial Coatings and Material Modification Strategies for Preventing Urinary Catheter-Associated Complications

In recent years, we have witnessed prominent improvements in urinary catheter coatings to tackle the commonly occurring catheter-associated urinary tract infection (CAUTI) in catheterized patients. CAUTIs are claimed to be one of the most frequent nosocomial infections that can lead to various complications, from catheter encrustation to severe septicaemia and pyelonephritis. Besides general prevention hygienic strategies, antimicrobial-coated urinary catheters show great potential in the prevention of urinary catheter-associated complications. The aim of this review is to present and evaluate recent updates on the development of antimicrobial urinary catheters in the context of the aetiology of urinary malfunction. Subsequently, we shed some light on future perspectives of utilizing 3D printing and the surrounding regulatory directions.

Analysis of the renewed European Medical Device Regulations in the frame of the non - EU regulatory landscape during the COVID facilitated change

The term "Medical devices" includes technology-based devices or articles, both basic and complex. Due to these types of variations, a strict, robust, transparent, and sustainable regulatory framework is required. In recent clinical practice, incidents including the breast implant and the hip replacement crisis have made it necessary to improve the regulatory and compliance approaches for the industry to ensure the manufacturing and distribution of safe and innovative MDs within the EU. In response to this, the EU revised the laws governing medical devices and in vitro diagnostics to align with the developments of the sector, address critical safety issues and support innovation. The new regulation (EU) 2017/745 on Medical Devices (MDR) is now applicable from May 26 2021 and the In Vitro Diagnostic Medical Devices Regulation (EU) 2017/746 will take effect from May 2022.In this review, we aim to provide an update on the new Medical Device Regulations in the context of the current medical needs of the world, and also to give a glimpse at the non-EU regulatory landscape. Finally, we take a look at the closed-system transfer devices (CSTD) and COVID facilitated changes promoting demand for continuous improvement and trends in the pharmaceutical and medical industry related areas.

Embolization therapy with microspheres for the treatment of liver cancer: State-of-the-art of clinical translation

Embolization with microspheres is a therapeutic strategy based on the selective occlusion of the blood vessels feeding a tumor. This procedure is intraarterially performed in the clinical setting for the treatment of liver cancer. The practice has evolved over the last decade through the incorporation of drug loading ability, biodegradability and imageability with the subsequent added functionality for the physicians and improved clinical outcomes for the patients. This review highlights the evolution of the embolization systems developed through the analysis of the marketed embolic microspheres for the treatment of malignant hepatocellular carcinoma, namely the most predominant form of liver cancer. Embolic microspheres for the distinct modalities of embolization (i.e., bland embolization, chemoembolization and radioembolization) are here comprehensively compiled with emphasis on material characteristics and their impact on microsphere performance. Moreover, the future application of the embolics under clinical investigation is discussed along with the scientific and regulatory challenges ahead in the field. STATEMENT OF SIGNIFICANCE: Embolization therapy with microspheres is currently used in the clinical setting for the treatment of most liver cancer conditions. The progressive development of added functionalities on embolic microspheres (such as biodegradability, imageability or drug and radiopharmaceutical loading capability) provides further benefit to patients and widens the therapeutic armamentarium for physicians towards truly personalized therapies. Therefore, it is important to analyze the possibilities that advanced biomaterials offer in the field from a clinical translational perspective to outline the future trends in therapeutic embolization.

Regulatory and risk oriented approach to the design and development of medical devices in accordance with Ukraine regulations

Based on the interpretation of regulatory requirements to describe the approach to risk-oriented medical devices design and development strategy and approaches to their certification in Ukraine market. The approach to the medical devices design and development strategy is described taking into account the classification by level of risk; a tree of decisions on determining the risk class and certification of medical devices according to the requirements of the Technical Regulation № 753 is presented.

[Mobile health for detection of atrial fibrillation-Status quo and perspectives]

Mobile health (mHealth) for the detection of atrial fibrillation is an innovative domestic monitoring of the heart rhythm. The use of mHealth in the context of atrial fibrillation increases the availability of diagnostic technologies and facilitates the integration into telemedical treatment concepts as well as the active participation of patients in the treatment process. The detection of atrial fibrillation with mHealth applications is usually based on electrocardiography (ECG) or by detection of the pulse wave using photoplethysmography (PPG). Some applications require additional sensors, others make use of sensors integrated into smartphones or smartwatches. A high diagnostic accuracy for the detection of atrial fibrillation has been shown for most mHealth applications regardless of the underlying technology (analytical validation); however, the evidence on positive care effects and improvement of medical endpoints (clinical validation) is so far scarce. Screening of symptomatic or asymptomatic patients and the follow-up care after antiarrhythmic measures are possibilities for the integration into the reality of care. The preventive detection of atrial fibrillation is an attractive field of application for mHealth with great potential for the future. Nevertheless, at present mHealth is only integrated to a limited extent into the reality of patient care. Adequate reimbursement and medical remuneration as well as opportunities to derive information and qualification are prerequisites in order to be able to guarantee a comprehensive implementation in the future. The Digital Health Care Act passed in 2019, regulates the reimbursement of digital healthcare applications but issues of primary preventive applications have not yet been included.