Proof of concept testing of a positive reference material for in vivo and in vitro sensitization testing of medical devices.

In vivo skin sensitization tests are required to evaluate the biological safety of medical devices in contact with living organisms to provide safe medical care to patients. Negative and positive reference materials have been developed for biological tests of cytotoxicity, implantation, hemolysis, and in vitro skin irritation. However, skin sensitization tests are lacking. In this study, polyurethane sheets containing 1 wt/wt % 2,4-dinitrochlorobenzene (DNCB-PU) were developed and evaluated as a positive reference material for skin sensitization tests. DNCB-PU sheet extracts prepared with sesame oil elicited positive sensitization responses for in vivo sensitization potential in the guinea pig maximization test and the local lymph node assay. Furthermore, DNCB-PU sheet extracts prepared with water and acetonitrile, 10% fetal bovine serum-containing medium, or sesame oil elicited positive sensitization responses as alternatives to animal testing based on the amino acid derivative reactivity assay, human cell line activation test, and epidermal sensitization assay, respectively. These data suggest that the DNCB-PU sheet is an effective extractable positive reference material for in vivo and in vitro skin sensitization testing in medical devices. The formulation of this reference material will lead to the development of safer medical devices that contribute to patient safety.

Japanese Regulatory Considerations for Interoperability of Medical Devices.

With the rapid technological innovations of the Internet of Things (IoT), the situation surrounding medical devices and medical systems has been changing. Interoperable medical devices-medical devices capable of interoperating in a clinically significant way with other medical devices-have been developed, and interoperable medical systems consisting of two or more interconnected interoperable medical devices are being used in clinical settings. However, general points that need to be considered to ensure safe and effective interoperability have yet to be fully established in Japan. A research project (FY2019-FY2021) to discuss issues associated with ensuring safe and effective interoperability was commissioned by the Japan Agency for Medical Research and Development. A pivotal aspect identified in that project is how to manage the sharing of data and information among interoperable medical devices from different manufacturers. Characteristics and timestamps of data and information need to be exchanged between interoperable medical devices. Risks associated with interoperable devices should be managed in a manner appropriate to the characteristics and the intended use of the interoperable medical devices. In this review, we summarize the aspects of data and information that this study group judged were important to consider for ensuring safety and effective interoperability.

Practice and Safety of Static Balloon Atrial Septostomy Based on a Nationwide Registry Data.

BACKGROUND: Balloon atrial septostomy (BAS) is an essential catheterization procedure for congenital heart lesions. Recently, a balloon catheter for static BAS was approved for the first time in Japan as an alternative to the conventional pull-through BAS. Despite the expected increase in the use of static BAS, reports on its safety are scarce worldwide.Methods and Results: Data on static and pull-through BAS registered in a national registry between 2016 and 2018 were collected. During the study period, 247 sessions of static BAS and 588 sessions of pull-through BAS were performed on a total of 674 patients. Patients who underwent static BAS were older (P<0.001). The incidence of serious adverse events (4.3% vs. 0.9%, P=0.03) and the overall incidence of adverse events (8.1% vs. 3.2%, P=0.03) were higher in static BAS than in pull-through BAS. Among patients who underwent static BAS, the risk factor for adverse events was a body weight <3 kg at the time of the procedure (odds ratio: 4.3 [confidence interval: 1.7-11], P=0.003). CONCLUSIONS: This nationwide study revealed differences in patient background between static and pull-through BAS, as well as a higher incidence of adverse events related to static BAS. Patients weighing <3 kg are at high risk for adverse events after static BAS and may require surgical and circulatory support backup.

[Investigation of Foreign Particles in Moderna COVID-19 Vaccine].

Particular batches of Moderna mRNA Coronavirus Disease 2019 (COVID-19) vaccine were recalled after foreign particles were found in some vaccine vials at the vaccination site in Japan in August 2021. We investigated the foreign particles at the request of the Ministry of Health, Labour and Welfare. Energy dispersive X-ray spectroscopy analysis suggested that the foreign particles found in the vials recalled from the vaccination sites were from stainless steel SUS 316L, which was in line with the findings of the root cause investigation by the manufacturer. The sizes of the observed particles ranged from <50 µm to 548 µm in the major axis. Similar foreign particles were also detected in 2 of the 5 vaccine vials of the same lot stored by the manufacturer, indicating that the foreign particles have already been administered to some people via vaccine. Observation of the vials of the same lot by digital microscope found smaller particles those were not detected by visual inspection, suggesting that more vials were affected. Contrarily, visual inspection and subvisible particulate matter test indicated no foreign particles in the vials of normal lots. Possible root cause and strategies to prevent such a deviation were discussed from technical and regulatory aspects.

In Vitro Measurement of Contact Pressure Applied to a Model Vessel Wall during Balloon Dilation by Using a Film-Type Sensor.

Objective: As an important evaluation index of vascular damage, the study aims to clarify the value of contact pressure applied to blood vessels and how it changes with respect to balloon pressure during balloon dilation. Methods: The contact pressure was evaluated through an in vitro measurement system using a model tube with almost the same elastic modulus as the blood vessel wall and our film-type pressure sensor. A poly (vinyl alcohol) hydrogel tube with almost the same elastic modulus was fabricated as the model vessel. The film-type sensor was inserted between the balloon catheter and the model vessel, and the balloon was dilated. Results: The contact pressure applied to the blood vessel was less than 10% of the balloon pressure, and the increase in contact pressure was less than 1% of the increase in balloon pressure (8 to 14 atm). Moreover, the contact pressure and its increase were larger in the model with a high elastic modulus. Conclusion: The contact pressure to expand the soft vessel model was not high, and the balloon pressure almost appeared to act on the expansion of the balloon itself. Our experiment using variable stiffness vessel models containing film-type sensors showed that the contact pressure acting on the vessel wall tended to increase as the wall became harder, even when the nominal diameter of the balloon was almost identical to the vessel. Our results can be clinically interpreted: when a vessel is stiff, the high-pressure inflation may rupture it even if its nominal diameter is identical to the diameter of the vessel.

In vitro evaluation of delamination resistance of PEEK and CFR-PEEK.

Poly-ether-ether-ketone (PEEK) and carbon fiber reinforced PEEK as orthopedic implant materials exhibit excellent material properties. Although delamination of PEEK materials has been reported in knee joint wear research, the delamination resistance behavior remains unclear. In this study, the delamination resistance of PEEK materials was investigated; these materials were compared to ultra-high molecular weight polyethylene (UHMWPE). The results of a ball-on-flat type delamination test indicated that the PEEK materials underwent delamination considerably earlier than UHMWPE, and the contact area of the PEEK materials was smaller than that of UHMWPE. Moreover, the indentation modulus, hardness, and coefficient of friction were higher for PEEK materials than for UHMWPE. The reduced tendency of PEEK materials to undergo deformation to mitigate stress concentration at low conformity contact conditions contributed to their inferior delamination resistance compared to that of UHMWPE. The delamination resistance of the PEEK materials was equivalent to that of degraded UHMWPE, which highlights the risk of delamination of PEEK implants in a clinical context. Consequently, when using PEEK materials as an implant component loaded at a low conformity contact condition, the material selection and component design must be carefully considered. Overall, the results of this study can help guide the future development of PEEK-based implants.

A web-based survey of contact lens-related adverse events among the Japanese female population.

To assess the safety of cosmetic contact lenses and to identify other factors of contact lens (CL)-related complications for Japanese females. A web-based, cross-sectional, observational survey of complications related to CL use was performed. The frequencies of complications were compared between transparent and cosmetic CLs. Besides lens pigmentation, age, replacement schedule, total experience, daily wear time, location of purchase, stacking of CLs, CL exchange with friends, compliance to hygiene procedure, replacement of CLs at intervals longer than recommended, and CL wear overnight were considered as risk factors. Logistic regression analyses were performed to calculate the odds ratios. A total of 3803 Japanese females were analyzed. The frequency of adverse events was 33.4% (95%CI 31.3-35.4%) and 35.7% (95%CI 33.5-38.0%) for transparent and cosmetic CLs, respectively. In a multivariate model, statistically significant factors associated with complications included the following: quarterly schedule lenses, replacement at intervals longer than recommended, compliance to hygiene procedure, overnight wearing, purchase at physical shops and on the internet, and longer daily wearing time. Most of the risk-increasing behaviors are preventable. The role of public health ophthalmology is to increase awareness and to improve CL use behaviors.

Stent Implantation for Congenital Heart Diseases in Japan　- Comprehensive Analysis From the Japanese Society of Congenital Interventional Cardiology Registry.

BACKGROUND: Stent implantation for vascular stenosis associated with congenital heart diseases is commonly performed as an off-label procedure in Japan because there is no officially approved stent for any congenital heart disease.Methods and Results:We analyzed data from the Japanese Society of Congenital Interventional Cardiology Registry collected from January 2016 to December 2018. Patients who underwent stent implantation were enrolled in the present analysis. During the study period, there were 470 procedures, 443 sessions, and 391 cases. Of 443 sessions, 427 (96.4%) succeeded procedurally. There were no differences in the procedural success rates among age groups. In all, 416 sessions (367 patients; 94%) resulted in survival to 30 days after catheter intervention. Of 392 admissions, 357 patients (91%) survived to discharge. Only 4 deaths were directly related to stent implantation. Some in-hospital complications were observed during 55 of 443 sessions. Both hospital deaths and serious complications were significantly more frequent in the group with various preoperative risk factors. CONCLUSIONS: Although not officially approved for congenital heart diseases in Japan, stent implantation in congenital heart diseases has been widely and routinely performed for many years with safety and efficacy. The aim of stenting was variable and broad because of many different applications and morphological variations. These data may facilitate approval of such an important device in Japan.

Performance evaluation of bactericidal effect and endotoxin inactivation by low-temperature ozone/hydrogen peroxide mixed gas exposure.

This study evaluated the performance of a new O3 /H2 O2 mixed gas sterilization instrument for killing microorganisms and inactivating bacterial endotoxin at low temperatures. Sterility assurance level was achieved by an over 6-log reduction of Geobacillus stearothermophilus ATCC 12980, and the decimal reduction value was 0.77 min in sterilization mode. A reduction of over 3 logs in Limulus amebocyte lysate coagulation activity of purified endotoxin from Escherichia coli was observed after treatment in endotoxin-inactivation mode. The same inactivation ability was observed when treating dried bacterial cells. Biomaterials made of polymer or metal did not exhibit cytotoxicity after gas exposure at O3 concentrations below 200 ppm. As the results of human cell-based pyrogen testing, significant amounts of endotoxin that were over the limit for medical devices contacting cerebrospinal fluid (2.15 EU/device) were detected on scissors washed with a washer-disinfector and sterilized with ethylene oxide or autoclaving. In contrast, endotoxin decreased to 0.29 ± 0.05 EU/device after O3 /H2 O2 mixed gas sterilization in endotoxin-inactivation mode. Compared to conventional gas sterilization methods, O3 /H2 O2 mixed gas has high sterilization ability and a strong capacity to inactivate endotoxin. It is expected that this sterilization technology will improve the safety of reusable medical devices and utensils for regenerative medicine.

[Evaluation of the Influence of Pharmaceuticals on the Mechanical Properties of Polymeric Medical Devices].

Pharmaceuticals reportedly cause damage to some polymeric medical devices that administer them. Because this phenomenon and its causes still remain unclear, in this study, all the possible combinations of polymeric materials and pharmaceutical ingredients that could cause failures were identified by conducting a comprehensive analysis on a wide variety of such combinations and through verification tests using the products. The results of the simple immersion tests and the reports of clinical failures indicated that the failures were not caused by the lack of chemical resistance of the polymers but by the environmental stress cracking (ESC) induced by a combination of the stress generated in the material and the interaction with a specific chemical. Therefore, we evaluated all combinations that could cause ESC by developing and applying a simple method for testing ESC. Polycarbonate and polyethylene terephthalate were found to be damaged by alkaline solutions and oils and fats, and surfactants solutions. These failures were also confirmed by the verification tests. Results from the stress state verification, fractographic analysis, and other studies confirmed that these failures were caused by ESC. Cytotoxicity owing to the induction of ESC was not detected in any combination. These results indicated that the residual stress generated during the manufacturing process was one of the reasons for the failure of the medical devices. This residual stress can be eliminated by employing additional processes such as annealing, thereby preventing medical device failures induced through interactions with pharmaceutical ingredients.

Novel cytokine marker available for skin irritation testing of medical devices using reconstructed human epidermis models.

In biological safety evaluation of medical devices, false-negative results have been observed during skin irritation testing using the reconstructed human epidermis (RhE) model when measuring cell viability as a single marker. Therefore, to improve testing accuracy, this study conducted a comprehensive survey and performance evaluation of cytokines to identify a second marker. In addition to IL-1α, macrophage migration inhibitory factor (MIF) was newly identified as a candidate marker, in the Bio-Plex assay of EpiDerm model exposed to polymer sample extracts. Irritation based on cell viability level was not accurately determined in LabCyte model using silicone spiked with 25% heptanoic acid (HA). By contrast, the irritation potency was accurately assessed in detail by measuring IL-1α or MIF. Further, IL-1α and MIF levels in EpiDerm, LabCyte, and EpiSkin models stimulated with sodium dodecyl sulfate (SDS) were inversely correlated with cell viability, and were detected even at low SDS concentrations without cell toxicity. Additionally, MIF demonstrated greater S/N ratio and dose-dependency at high SDS concentrations in some models compared to IL-1α. These results indicated that MIF might be a useful second marker for improving the sensitivity and accuracy of skin irritation testing with RhE models.

In vitro estimation of reduction in strength and wear resistance of UHMWPE for joint prostheses due to lipid-induced degradation.

Ultra-high molecular weight polyethylene (UHMWPE) is used as a bearing surface of joint prostheses and has been reported to absorb lipids such as squalene (SQ) and cholesterol esters in vivo. These lipids have been suggested by in vitro studies using SQ as a model lipid to have the potential to induce polymer degradation. However, the impact of lipid-induced degradation on the strength and wear resistance of UHMWPE is unknown. In this study, lipid-induced degradation was simulated by SQ absorption and subsequent accelerated aging, and its influence on the strength and wear resistance of UHMWPE was investigated using wear, fatigue crack growth, and delamination testing. Lipid-induced degradation was found to have little impact on fatigue crack growth rates and delamination resistance. These results were consistent with previous reports that lipid-induced degradation is localized near the surface. However, we also found that lipid-induced degradation increased the wear rate of both non-crosslinked and crosslinked UHMWPE by a factor of 2.5 and 14, respectively. These results indicate that lipid-induced degradation may affect the durability and long-term clinical outcome of joint replacements due to increased wear of UHMWPE.

A novel method to eliminate the influence of absorbed lipids on the characterization of ultra-high molecular weight polyethylene using Fourier-transform infrared spectroscopy.

BACKGROUND: Fourier-transform infrared spectroscopy (FTIR) is one of the standard methods to analyze ultra-high molecular weight polyethylene (UHMWPE) in orthopedic implants. For retrieved components, lipid extraction using an organic solvent prior to the measurement is necessary to eliminate the influence of lipids absorbed in vivo. However, its influence on the measurement has not been substantially investigated. OBJECTIVE: To investigate the influence of lipid extraction on the FTIR analysis of UHMWPE and to develop a novel method to obtain reliable results without inconvenient lipid extraction. METHODS: FTIR analysis was repeatedly performed on UHMWPE specimens from retrieved components before and after lipid extraction under various conditions. A method to calculate the extent of influence of the absorbed lipids from the FTIR spectra was developed using a peak separation technique. RESULTS: An elevated temperature was necessary for lipid extraction; however, it had the potential to influence the results if the conditions were not properly controlled. The results obtained using the peak separation technique coincided with those obtained after lipid extraction. CONCLUSION: The use of the peak separation technique enables the efficient acquisition of reliable results without the need for lipid extraction.

Evaluating the durability of UHMWPE biomaterials used for articulating surfaces of joint arthroplasty using delamination tests.

Ultra-high molecular weight polyethylene (UHMWPE) is the most popular material used for the articulating surface of joint replacements. Delamination is a common fatigue-related failure mode in UHMWPE components; however, the relationship between delamination resistance and fatigue crack growth has not been reported. Here, the delamination resistance of contemporary UHMWPE materials, including highly cross-linked UHMWPE (HXLPE), vitamin E blended UHMWPE (VEPE), and vitamin E blended HXLPE (VEXLPE), was measured to verify a previously proposed accelerated test method using a U-shaped sliding motion; the results were compared with those of fatigue crack growth tests. The oxidative stability of each material was estimated using Fourier transform infrared analysis. UHMWPE sterilized by gamma irradiation in an inert atmosphere and annealed HXLPE had lower delamination resistance than virgin UHMWPE after artificial aging. This was consistent with previous findings from retrieval studies, and in vitro knee simulator and ball-on-flat unidirectional reciprocation wear studies. In contrast, remelted HXLPE, VEPE, and VEXLPE showed excellent delamination resistance after artificial aging. The results of the delamination tests were not consistent with those of fatigue crack growth tests, indicating the complex delamination mechanism and importance of evaluating these factors separately. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 107B: 65-72, 2019.

A biological study establishing the endotoxin limit for osteoblast and adipocyte differentiation of human mesenchymal stem cells.

INTRODUCTION: Multipotent mesenchymal stem cells (MSCs) are widespread in adult organisms and are implicated in tissue maintenance and repair, regulation of hematopoiesis, and immunologic responses. Human (h)MSCs have applications in tissue engineering, cell-based therapy, and medical devices but it is unclear how they respond to unfavorable conditions, such as hypoxia or inflammation after transplantation in vivo. Although endotoxin testing is required for evaluating the quality and safety of transplanted MSCs, no reports on their dose response to endotoxins are available to establish the limits for in vitro MSC culture systems. In the present study, we aimed to accurately quantify the risk of endotoxin contamination in cell culture systems to establish an acceptable endotoxin limit for the differentiation of hMSC osteoblasts and adipocytes. METHODS: Three types of bone marrow-derived hMSCs (hMSC-1: 21-year-old, M/B; hMSC-2: 36-year-old, M/B; hMSC-3: 43-year-old, M/C) and adipose-derived stem cells (ADSCs; StemPro Human) were cultured in osteogenic or adipogenic differentiation media, respectively, from commercial kits, containing various concentrations of endotoxin (0.01-100 ng/ml). The degree of adipocyte and osteoblast differentiation was estimated by fluorescent staining of lipid droplets and hydroxyapatite, respectively. To clarify the molecular mechanism underlying the effect of endotoxin on hMSC differentiation, cellular proteins were extracted from cultured cells and subjected to liquid chromatograph-tandem mass spectrometry shotgun proteomics analysis. RESULTS: Although endotoxin did not effect the adipocyte differentiation of hMSCs, osteoblast differentiation was enhanced by various endotoxin concentrations: over 1 ng/ml, for hMSC-1; 10 ng/ml, for hMSC-2; and 100 ng/ml, for hMSC-3. Proteomic analysis of hMSC-1 cells revealed up-regulation of many proteins related to bone formation. These results suggested that endotoxin enhances the osteoblast differentiation of MSCs depending on the cell type. CONCLUSIONS: Since endotoxins can affect various cellular functions, an endotoxin limit should be established for in vitro MSC cultures. Its no-observed-adverse-effect level was 0.1 ng/ml based on the effect on the hMSC osteoblast differentiation, but it may not necessarily be the limit for ADSCs.

Evaluation of Pigment Distribution and Depth Analysis Methods for Decorative Soft Contact Lenses.

OBJECTIVES: This study evaluates pigment component distribution and depth in decorative soft contact lenses (DSCLs) using a variety of analytical methods. METHODS: We sampled 18 DSCLs using optical microscopy, optical coherence tomography analysis, Z-stack analysis, X-ray photoelectron spectroscopy (XPS), scanning electron microscopy/energy-dispersive X-ray spectroscopy (SEM/EDX), and time-of-flight secondary ion mass spectrometry (TOF-SIMS) to evaluate the distribution and depth of pigment components. RESULTS: Pigment distribution in DSCLs was easily observed with optical methods including Z-stack analysis. X-ray photoelectron spectroscopy, SEM/EDX, and TOF-SIMS were used to evaluate the level of pigment exposure on the lens surface and the results showed significant differences between the methods. Pigment components were detected in 16 samples by SEM/EDX, but not by XPS. Pigment components were only detected in eight samples using TOF-SIMS. CONCLUSIONS: It may be necessary to show that a nanometer-thick monomolecular film does not exist on the surface of DSCLs, to demonstrate the exposure of a pigment particle. Taking into account the principle behind each of the measurement methods and the resolution and sensitivity of each of the analytical methods compared, TOF-SIMS may be the most appropriate method to accurately judge pigment exposure on DSCLs. The Z-stack method may be useful for estimating the depth of pigment components in DSCLs.

Proof of concept testing of a positive reference material for in vivo and in vitro skin irritation testing.

In vivo and in vitro irritation testing is important for evaluating the biological safety of medical devices. Here, the performance of positive reference materials for skin irritation testing was evaluated. Four reference standards, referred to as Y-series materials, were analyzed: a polyvinyl chloride (PVC) sheet spiked with 0 (Y-1), 1.0 (Y-2), 1.5 (Y-3), or 10 (Y-4) parts of Genapol X-080 per 100 parts of PVC by weight. Y-1, Y-2, and Y-3 did not induce skin irritation responses in an in vitro reconstructed human epidermis (RhE) tissue model, as measured by tissue viability or interleukin-1α release, or in an in vivo intracutaneous response test using rabbits. In contrast, Y-4 extracts prepared with saline or sesame oil at 37°C and 50°C clearly elicited positive irritation responses, including reduced viability (< 50%) and significantly higher interleukin-1α release compared with the solvent alone group, in the RhE tissue model and an intracutaneous response test, where substantial necrosis was observed by histopathology. The positive skin irritation responses induced in vitro under various extraction conditions, as well as those elicited in vivo, indicate that Y-4 is an effective extractable positive control material for in vivo and in vitro skin irritation tests of medical devices. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2807-2814, 2018.

Alternative plasticizer, 4-cyclohexene-1,2-dicarboxylic acid dinonyl ester, for blood containers with protective effects on red blood cells and improved cold resistance.

Di (2-ethylhexyl) phthalate (DEHP), a typical plasticizer used for polyvinyl chloride (PVC), is eluted from PVC-made blood containers and protects against red blood cell (RBC) hemolysis. However, concerns have arisen regarding the reproductive and developmental risks of DEHP in humans, and the use of alternative plasticizers for medical devices has been recommended worldwide. In this study, we propose that the use of a novel plasticizer, 4-cyclohexene-1,2-dicarboxylic acid dinonyl ester (DL9TH), could help produce more useful and safe blood containers. PVC sheet containing DL9TH and di (2-ethylhexyl) 4-cyclohexene-1,2-dicarboxylate (DOTH) provides comparable or superior protective effects to RBCs relative to PVC sheet containing DEHP or di-isononyl-cyclohexane-1,2-dicarboxylate (DINCH® , an alternative plasticizer that has been used in PVC sheets for blood containers). The total amount of plasticizer eluted from DOTH/DL9TH-PVC sheets is nearly the same as that eluted from DEHP-PVC sheets. In addition, DOTH/DL9TH-PVC has better cold resistance than DEHP- and DINCH® -PVC sheets. In vitro and in vivo tests for biological safety based on International Organization for Standardization guidelines (10993 series) suggest that the DOTH/DL9TH-PVC sheet can be used safely. Subchronic toxicity testing of DL9TH in male rats in accordance with the principles of Organisation for Economic Co-operation and Development Test Guideline 408 showed that DL9TH did not induce adverse effects up to the highest dose level tested (717 mg/kg body weight/day). There were no effects on testicular histopathology and sperm counts, and no indications of endocrine effects: testosterone, thyroid-stimulating hormone, follicle-stimulating hormone, and 17ß-estradiol were unchanged by the treatment, compared with the control group. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1052-1063, 2018.