How can the environmental sustainability of healthcare products be taken into account throughout their life cycle?

Healthcare product procurement accounts for around 50% of the French healthcare system's greenhouse gas emissions. This lesson learned from the publication of the Shift Project's work in November 2021 has been a catalyst within the healthcare system, accelerating the consideration and implementation of actions aimed at reducing the environmental impact of the healthcare system, before, during and after care. In addition to their carbon footprint, healthcare products have a wide range of environmental impacts, including on water, air and soil, throughout their entire life cycle. We have chosen to divide this life cycle into four main stages: from research and development to production, distribution and market access, use and finally end-of-life management. Analysis of the regulatory framework at each stage and of existing initiatives described in the literature or by those in the field have structured and fuelled our thinking. We found that existing regulations focus exclusively on the health risk, with little or no consideration of the environmental risk, which is in itself a health risk. Furthermore, the implementation of certain structuring actions during the first 3 stages of the life cycle would make it possible to simplify or even eliminate the major problem of waste management associated with the end-of-life of healthcare products. With this in mind, we have produced 9 recommendations to ensure that the environmental impact of healthcare products is better taken into account throughout their life cycle.

Real-time algorithmic exchange and processing of pharmaceutical quality data and information

Herein, a modern method is proposed for exchanging and processing real-time medicinal product information using Health Level 7 International's (HL7) Fast Healthcare Interoperability Resources (FHIR®) standard, Application Programming Interfaces (API), digitization and artificial intelligence. FHIR is presently in use largely to facilitate interactions between patient-facing healthcare institutions, such as hospitals, doctor's offices, and laboratories, for electronic health record management and exchange. There are several ongoing efforts to adapt the FHIR standard for regulatory use cases to support the needs of the global biopharmaceutical industry, including the exchange of Electronic Product Information (ePI); chemistry, manufacturing, and controls (CMC) data; and adverse event reporting. Once in place, this new method of data exchange is expected to (1) improve efficiency by reducing the time and effort needed to manage regulatory information; (2) accelerate decision making; (3) encourage innovation in pharmaceutical manufacturing; (4) improve the ability and agility of information exchange. Currently, the end-to-end timescale for the pharmaceutical regulatory workflow is measured in months and years. This new paradigm will use FHIR APIs and other supporting technologies to reduce the potential time for data exchange from months to days, hours, minutes, and eventually sub-seconds. With such drastic improvements in speed provided by digitization, automation, and interoperability, the biopharmaceutical industry can reach more patients, and more quickly than at any time in the industry's 100+ year history. The present work will focus on examining specific real-world implementation examples for using FHIR to support exchange of CMC information within and across the biopharmaceutical industry.

Spatial variation of rodenticides and emerging contaminants in blood of raptor nestlings from Germany

Wildlife exposures to pest controlling substances have resulted in population declines of many predatory species during the past decades. Many pesticides were subsequently classified as persistent, bioaccumulative, and toxic (PBT) and banned on national or global scales. However, despite their risks for non-target vertebrate wildlife, PBT substances such as anticoagulant rodenticides (ARs) are still permitted for use in Europe and have shown to threaten raptors. Whereas risks of ARs are known, much less information is available on emerging agrochemicals such as currently used PPPs and medicinal products (MPs) in higher trophic level species. We expect that currently used PPPs are relatively mobile (vs. lipophilic) as a consequence of the PBT criteria and thus more likely to be present in aqueous matrices. We therefore analyzed blood of 204 raptor nestlings of three terrestrial (red kite, common buzzard, Montagu's harrier) and two aquatic species (white-tailed sea eagle, osprey) from Germany. In total, we detected ARs in 22.6% of the red kites and 8.6% of the buzzards, whereas no Montagu's harriers or aquatic species were exposed prior to sampling. ΣAR concentration tended to be higher in North Rhine-Westphalia (vs. North-Eastern Germany) where population density is higher and intense livestock farming more frequent. Among the 90 targeted and currently used PPPs, we detected six substances from which bromoxynil (14.2%) was most frequent. Especially Montagu's harrier (31%) and red kites (22.6%) were exposed and concentrations were higher in North Rhine-Westphalia as well. Among seven MPs, we detected ciprofloxacin (3.4%), which indicates that risk mitigation measures may be needed as resistance genes were already detected in wildlife from Germany. Taken together, our study demonstrates that raptors are exposed to various chemicals during an early life stage depending on their sampling location and underpins that red kites are at particular risk for multiple pesticide exposures in Germany.

[Instruments of official communication by regulatory authorities on risks of drug use]

Active communication of authorities, such as the Federal Institute for Drugs and Medical Devices (BfArM) and the Paul Ehrlich Institute (PEI), including maintenance of contacts with health care professionals, as well as press and public relations work, are essential prerequisites for ensuring that information on the risks of using medicinal products reaches both affected patients and healthcare professionals quickly and in a targeted manner. The various instruments of targeted communication describe possible risks and also contain recommendations that help to reduce the risk of using a medicinal product. The supplementary public relations work aims to make the tasks and objectives of the authority known to the public and to experts with the goal of creating and expanding trust in the actions of the authorities. To this end, appropriate communication platforms must be established and accepted so that they are used by both experts and the general public and the authority is perceived and appreciated as a reliable source of risk information. The currently available instruments of targeted risk communication, such as Dear Health Care Professional Communication (DHPC), risk management plans, and educational materials are described in this paper as well as broader communication on official websites or towards the media. Finally, PEI's risk communication is highlighted with particular reference to COVID-19 vaccines.

[Disinfectants during the COVID-19 pandemic: a challenge]

Disinfection measures have become more important as a result of the COVID-19 pandemic in Germany. The increased need for disinfectants at the beginning of the pandemic required temporary legal regulations in order to provide a sufficient quantity of products for the necessary disinfection in the medical sector on the one hand and for the additional demand in the population on the other. For this purpose, the Federal Institute for Drugs and Medical Devices (BfArM) and the Federal Institute for Occupational Safety and Health (BAuA) issued a general ruling, which is explained in more detail in this article. The focus was on measures for hygienic hand disinfection. However, other applications such as surface disinfection in relation to pandemic respiratory diseases are also addressed. The experience gained in ensuring the supply of disinfectants that are effective and safe to use should be used to prepare for further pandemics.

Development of extracellular vesicle-based medicinal products: A position paper of the group "Extracellular Vesicle translatiOn to clinicaL perspectiVEs - EVOLVE France"

Extracellular vesicles (EV) are emergent therapeutic effectors that have reached clinical trial investigation. To translate EV-based therapeutic to clinic, the challenge is to demonstrate quality, safety, and efficacy, as required for any medicinal product. EV research translation into medicinal products is an exciting and challenging perspective. Recent papers, provide important guidance on regulatory aspects of pharmaceutical development, defining EVs for therapeutic applications and critical considerations for the development of potency tests. In addition, the ISEV Task Force on Regulatory Affairs and Clinical Use of EV-based Therapeutics as well as the Exosomes Committee from the ISCT are expected to contribute in an active way to the development of EV-based medicinal products by providing update on the scientific progress in EVs field, information to patients and expert resource network for regulatory bodies. The contribution of our work group "Extracellular Vesicle translatiOn to clinicaL perspectiVEs - EVOLVE France", created in 2020, can be positioned in complement to all these important initiatives. Based on complementary scientific, technical, and medical expertise, we provide EV-specific recommendations for manufacturing, quality control, analytics, non-clinical development, and clinical trials, according to current European legislation. We especially focus on early phase clinical trials concerning immediate needs in the field. The main contents of the investigational medicinal product dossier, marketing authorization applications, and critical guideline information are outlined for the transition from research to clinical development and ultimate market authorization.

Evaluating the frequency, consumers' motivation and perception of online medicinal, herbal, and health products purchase safety in Saudi Arabia

Objectives

Purchasing medicinal products from the internet has become more popular in the last three decades. Understanding consumers’ use and perception of the safety of medicinal products obtained online is essential. Therefore, this study aims to evaluate the extent of medicines purchased from the internet in Saudi Arabia, types of products, sources of information, the satisfaction, the motivational factors, and estimate consumers’ vigilance and tendency to report ADRs if occurred.

Design

A prospective cross-sectional study using a custom-designed questionnaire was conducted among community adults in Saudi Arabia, age ≥ 18.

Setting

Evaluation of community subjects' perception towards buying medicinal products was done through the internet in Saudi Arabia from 1st July 2020 until the end of August 2020.

Main outcome measure(s)

The main outcome of the study was purchasing medicinal products from the internet (Yes, No).

Results

Overall, 36% of the study participants (n = 643) have ever bought medicinal products from the internet (Table 2). Of those, the most obtained was herbal medicine, supplements, or cosmetics (61.3%). Motivational factors towards purchasing medicinal products from the internet were mostly positive, with the most commonly reported agreed motivational factors were lower cost (55.7%), easy online access (54.1%), a wide variety of products (52.6%), and more privacy (43.6%). Around 60.4% of participants believed that buying medicinal products from the internet can be safe. The most perceived risk was the difficulty of distinguishing between registered online pharmacies and other unlicensed commercial websites, with only 32.7% of the participants distinguishing between registered and unlicensed commercial websites.

Conclusions

This study sheds light on the consumers’ use and perception of the safety and risks of medicinal products purchased from the internet. The study findings noticeably describe the great need to increase safety awareness about obtaining medicinal products from the internet among the Saudi community.

Linking landscape composition and biological factors with exposure levels of rodenticides and agrochemicals in avian apex predators from Germany

Intensification of agricultural practices has resulted in a substantial decline of Europe's farmland bird populations. Together with increasing urbanisation, chemical pollution arising from these land uses is a recognised threat to wildlife. Raptors are known to be particularly sensitive to pollutants that biomagnify and are thus frequently used sentinels for pollution in food webs. The current study focussed on anticoagulant rodenticides (ARs) but also considered selected medicinal products (MPs) and frequently used plant protection products (PPPs). We analysed livers of raptor species from agricultural and urban habitats in Germany, namely red kites (MIML; Milvus milvus), northern goshawks (ACGE; Accipiter gentilis) and Eurasian sparrowhawks (ACNI; Accipiter nisus) as well as white-tailed sea eagles (HAAL; Haliaeetus albicilla) and ospreys (PAHA; Pandion haliaetus) to account for potential aquatic exposures. Landscape composition was quantified using geographic information systems. The highest detection of ARs occurred in ACGE (81.3%; n = 48), closely followed by MIML (80.5%; n = 41), HAAL (38.3%; n = 60) and ACNI (13%; n = 23), whereas no ARs were found in PAHA (n = 13). Generalized linear models demonstrated (1) an increased probability for adults to be exposed to ARs with increasing urbanisation, and (2) that species-specific traits were responsible for the extent of exposure. For MPs, we found ibuprofen in 14.9% and fluoroquinolones in 2.3% in individuals that were found dead. Among 30 investigated PPPs, dimethoate (and its metabolite omethoate) and thiacloprid were detected in two MIML each. We assumed that the levels of dimethoate were a consequence of deliberate poisoning. AR and insecticide poisoning were considered to represent a threat to red kites and may ultimately contribute to reported decreased survival rates. Overall, our study suggests that urban raptors are at greatest risk for AR exposure and that exposures may not be limited to terrestrial food webs.

Quantitative Benefit-Risk Assessment: State of the Practice Within Industry

BACKGROUND

Benefit-risk assessments for medicinal products and devices have advanced significantly over the past decade. The purpose of this study was to characterize the extent to which the life sciences industry is utilizing quantitative benefit-risk assessment (qBRA) methods.

METHODS

Semi-structured interviews were conducted with a sample of industry professionals working in drug and/or medical device benefit-risk assessments (n = 20). Questions focused on the use, timing, and impact of qBRA; implementation challenges; and future plans. Interviews were recorded, transcribed, and coded for thematic analysis.

RESULTS

While most surveyed companies had applied qBRA, application was limited to a small number of assets-primarily to support internal decision-making and regulatory submissions. Positive impacts associated with use included improved team decision-making and communication. Multi-criteria decision analysis and discrete choice experiment were the most frequently utilized qBRA methods. A key challenge of qBRA use was the lack of clarity regarding its value proposition. Championing by senior company leadership and receptivity of regulators to such analyses were cited as important catalysts for successful adoption of qBRA. Investment in qBRA methods, via capability building and pilot studies, was also under way in some instances.

CONCLUSION

qBRA application within this sample of life sciences companies was widespread, but concentrated in a small fraction of assets. Its use was primarily for internal decision-making or regulatory submissions. While some companies had plans to build further capacity in this area, others were waiting for further regulatory guidance before doing so.

Mapping Physicians' Experiences with Medicinal Products from Whole Medical Systems: A Descriptive Analysis of the Vademecum of Anthroposophic Medicines

BACKGROUND

Therapy in whole medical systems involves a large number of medicinal products. One source of knowledge of clinical properties of such products is the experience of therapy providers. A systematic approach to documentation, assessment, and aggregation of physicians' experiences with anthroposophic medicinal products (AMPs) has been developed: the Vademecum of Anthroposophic Medicines.

MATERIAL AND METHODS

The Vademecum contains structured information on AMPs, including therapeutic rationale, indications, and therapy recommendations. The information is based on a 17-item questionnaire of physicians' therapy experiences, which is peer-reviewed by an interdisciplinary editorial board. We conducted a descriptive analysis of the Vademecum, 4th edition.

RESULTS

The Vademecum comprised 799 different AMPs, used for 1,773 indications, based on 2,543 questionnaires submitted by 274 physicians from 19 countries. The 799 AMPs comprised 52.6% of all AMPs marketed in Germany in 2015-2016. The 1,773 indications corresponded to 544 different ICD-10 three-digit codes, amounting to 29.3% (n = 544/1,854) of all three-digit codes. A total of 30.6% (n = 542/1,773) of indications were supported by ≥2 questionnaires.

CONCLUSIONS

The current Vade-mecum covers more than half of all AMPs, used for more than one fourth of all ICD-10 three-digit codes. The Vademecum approach may be relevant for medicinal products from other whole medical systems.

[Toxicity of heavy liquids]

BACKGROUND

Acute toxicity of perfluorocarbon liquids (PFCL) is a relevant problem in retinal surgery due to impurities in the medicinal product.

OBJECTIVE

This article gives an overview of the current problems, possible explanations, interactions with other medicinal products and approaches to improved patient safety.

RESULTS

Toxicity is caused by impurities in the raw material but can also be caused by interactions with other medicinal products or drugs. The current test procedures do not ideally represent the ophthalmological application but there are promising activities to set the course for the future.

CONCLUSION

The use of PFCL in retinal surgery is generally considered safe. Users should pay attention to the quality of medicinal products.

The New SNOMED CT International Medicinal Product Model

OBJECTIVES

To present the new SNOMED CT international medicinal product model.

METHODS

We present the main elements of the model, with focus on types of entities and their interrelations, definitional attributes for clinical drugs, and categories of groupers.

RESULTS

We present the status of implementation as of July 2018 and illustrate differences between the original and new models through an example.

CONCLUSIONS

Benefits of the new medicinal product model include comprehensive representation of clinical drugs, logical definitions with necessary and sufficient conditions for all medicinal product entities, better high-level organization through distinct categories of groupers, and compliance with international standards.

Skin care in nursing: A critical discussion of nursing practice and research

Skin (self-)care is part of human life from birth until death. Today many different skin care practices, preferences, traditions and routines exist in parallel. In addition, preventive and therapeutic skin care is delivered in nursing and healthcare by formal and informal caregivers. The aim of this contribution is a critical discussion about skin care in the context of professional nursing practice. An explicit skin assessment using accurate diagnostic statements is needed for clinical decision making. Special attention should be paid on high risk skin areas, which may be either too dry or too moist. From a safety perspective the protection and maintenance of skin integrity should have the highest priority. Skin cleansing is the removal of unwanted substances from the skin surface. Despite cleansing efficacy soap, other surfactants and water will inevitably always result in the destruction of the skin barrier. Thousands of products are available to hydrate, moisturize, protect and restore skin properties dependent upon their formulation and the concentration of ingredients. These products intended to left in contact with skin exhibit several actions on and in the skin interfering with skin biology. Unwanted side effects include hyper-hydration and disorganization of lipid bilayers in the stratum corneum, a dysfunctional barrier, increased susceptibility to irritants and allergies, and increases of skin surface pH. Where the skin barrier is impaired appropriate interventions, e.g. apply lipophilic products in sufficient quantity to treat dry skin or protect the skin from exposure to irritants should be provided. A key statement of this contribution is: every skin care activity matters. Every time something is placed on the skin, a functional and structural response is provoked. This response can be either desired or undesired, beneficial or harmful. The choice of all skin care interventions in nursing and healthcare practice must be based on an accurate assessment of the skin and concomitant health conditions and on a clearly defined outcome. A standardized skin care and skin care product language is needed for researchers planning and conducting clinical trials, for reviewers doing systematic reviews and evidence-base summaries, for nurses and other healthcare workers to deliver evidence-based and safe skin care.

Regulation of Cell and Gene Therapy Medicinal Products in Taiwan

Owing to the rapid and mature development of emerging biotechnology in the fields of cell culture, cell preservation, and recombinant DNA technology, more and more cell or gene medicinal therapy products have been approved for marketing, to treat serious diseases which have been challenging to treat with current medical practice or medicine. This chapter will briefly introduce the Taiwan Food and Drug Administration (TFDA) and elaborate regulation of cell and gene therapy medicinal products in Taiwan, including regulatory history evolution, current regulatory framework, application and review procedures, and relevant jurisdictional issues. Under the promise of quality, safety, and efficacy of medicinal products, it is expected the regulation and environment will be more flexible, streamlining the process of the marketing approval of new emerging cell or gene therapy medicinal products and providing diverse treatment options for physicians and patients.

Reflections on Decisions Made on the Well-Established Use of Medicinal Products by EU Regulators and the ECJ

Background: In the European Union (EU), a medicinal product needs a marketing authorization (MA) to be placed on the market. The EU’s medicinal products’ legislative framework allows for a reduced application for medicines outside their data exclusivity. One such type of application is the well-established use (WEU) medicinal product application (i.e. bibliographic applications). Recently, these MA applications have been subject to arbitration procedures at the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) because of disagreements between member states during the authorisation process. This paper reflects on these cases and highlights their potential impact on future WEU applications.

Methods: Decisions adopted by the European Commission on WEU applications between 2009 and 2012 were identified from the EU Community Register on medicinal products for human use. Subsequently, decisions were reviewed to understand the potential serious risk to public health (PSRPH) that EU regulators raised during MA application procedures.

Results: Four decisions were adopted by the EU commission between 2009 and 2012. Three followed disagreements between member states on PSRPH grounds. One decision was the outcome of a centralised marketing authorisation application. Six key messages were identified from the four cases reviewed and presented.

Conclusion: A guideline on WEU to implement the technical specifications to fulfil Annex I of Directive 2001/83/EC for MA applications is not available. Thus, reflections on recent decisions on WEU applications provide scientific direction to the industry as well as the medicinal product regulators on the documentation required to successfully file and obtain a WEU MA.