Demographics of patients receiving Intravitreal anti-VEGF treatment in real-world practice: healthcare research data versus randomized controlled trials

BACKGROUND

While randomized controlled trials (RCTs) are based on strict inclusion/exclusion criteria, non-interventional studies (NISs) might provide additional information to guide management in patients more representative to the real-world setting. The aim of this study was to compare baseline characteristics of patients receiving intravitreal treatment in the NIS OCEAN with those from published RCTs.

METHODS

The ongoing OCEAN study enrolled patients treated with ranibizumab for neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME) or branch/central retinal vein occlusion (B/CRVO). Baseline patient characteristics were compared by indication within the OCEAN cohort. Furthermore, the characteristics were set in reference to those of published RCTs in the same indications. Confidence intervals (CIs) were calculated and assessed for statistically significant differences as indicated by non-overlapping CIs.

RESULTS

Patient characteristics in the NIS OCEAN were evaluated for 3,614 patients with nAMD, 1,211 with DME, 204 with BRVO and 121 with CRVO. Between these groups, significant differences in mean age, gender distributions, and mean baseline VA were seen, reflecting known differences between the indications. Compared to the patient characteristics of published RCTs (trials selected by literature search: nAMD: 13 RCTs, DME: 9, RVO: 5), the OCEAN patients' mean age was significantly higher in every indication. The gender distributions across the trials were comparable, with only few differences between OCEAN and the RCTs. Regarding the mean baseline VA, notable differences were found in nAMD and in DME, with VA significantly higher in some RCTs and lower in others.

CONCLUSIONS

The described differences underline the complementarity of NISs and RCTs. OCEAN covers a broader spectrum and more variability of patients than do RCTs. As baseline values may have impact on the treatment response (ceiling effect), there is an ongoing need for research in all patient subgroups. Country-specific assessments of patient populations can better reflect the real-world situation. NISs can deliver insights that RCTs may not, as NISs can include non-typical patients, patients with comorbidities, a broader age spectrum and patients of various disease stages.

TRIAL REGISTRATION

The NIS OCEAN was registered on www.clinicaltrials.gov (identifier: NCT02194803 ).

Conditions for enhancing the encoding of an elementary motor memory by rTMS

OBJECTIVE

Motor learning results in changes of movement representation in primary motor cortex (M1) a process involving long-term potentiation (LTP). Pairing motor training with repetitive transcranial magnetic stimulation (rTMS) of M1 enhances the formation of a motor memory. Here we determined the effect of pairing M1 stimulation and the execution of training movements at different times and frequencies on the formation of a motor memory.

METHODS

Formation of a motor memory was defined as increases in motor evoked potentials (MEP) of the training agonist (extensor carpi ulnaris muscle, ECU) and increases in peak acceleration of the trained movements that last more than 60min. Training consisted of auditory-paced ballistic wrist extension movements (30min, 0.5Hz) paired with 0.1, 0.25 or 0.5Hz subthreshold rTMS. The rTMS pulse was applied at either the onset, 100ms prior to or 300ms after the onset of training movement related increases in electromyographic (EMG) activity of ECU. This was compared to a Sham condition.

RESULTS

Only 0.1Hz rTMS applied at the onset of the training related increase in ECU-EMG activity resulted in increases in MEP amplitudes and peak acceleration when compared to the Sham.

CONCLUSIONS

The formation of motor memory is enhanced above the naïve level by co-administration of low frequency rTMS at the time of execution of training movements.

SIGNIFICANCE

These results indicate the importance of time and frequency of rTMS in these settings and should be considered in the design of rehabilitation treatment strategies using rTMS.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : VI. ON THE VIRULENCE OF THE OVERGROWTH IN THE LYSED CULTURES OF BACILLUS PESTIS CAVIAE (M. T. II)

Resistants isolated from the overgrowth of cultures of B. pestis caviæ (M. T. II) lysed by various strains of specific bacteriophage proved to be avirulent when administered to mice by feeding, or by intraperitoneal injection. These cultures remained resistant to the action of bacteriophage so long as they were carried on agar. When transferred to broth, however, one group of resistants, namely, those isolated by means of "weak" phages, became susceptible to lysis after five to seven daily passages. The other group of resistants, isolated from the cultures lysed by one of the "strong" phages, failed to become susceptible to lysis even after nearly 200 passages in broth. Simultaneously with the recovery of susceptibility, the cultures of the first group regained a degree of virulence comparable to that of the parent culture of B. pestis caviæ. The cultures of the second group of resistants have failed thus far to recover virulence (10 months after isolation). The latter cultures, apart from lack of both virulence and susceptibility to lysis, are identical with the parent culture of B. pestis caviæ, as indicated by biochemical and antigenic properties. Our findings offer evidence in favor of the view that resistant strains result from selection among variants already existing in the parent culture and do not arise through the inheritance of specific immunity properties produced by the action of phage.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : IV. CONCERNING THE ONENESS OF THE BACTERIOPHAGE

Lytic filtrates, active against Bacillus dysenterioe Shiga, Bacillus coli, Bacillus pestis cavioe, and staphylococcus respectively, proved to be differently affected by changes in hydrogen ion concentration. Anti-staphylococcus lysin was the least resistant of the four, showing deterioration in 3 hours at 7 degrees C. beyond the zone of hydrogen ion concentration limited by C(H) = 6.3 x 10(-5) and C(H) = 1.6 x 10(-9). Under the same conditions, the zone of resistance of anti-coli filtrate lay between C(H) = 2.7 x 10(-3) and C(H) = 2.5 x 10(-11), and that of anti-Shiga between C(H) = 1-7 x 10(-4) and C(H) = 1-3 x 10(-11). Anti-pestis cavioe filtrate was most resistant of the four, retaining its full activity in the zone from C(H) = 1 x 10(-3) to C(H) = 3.5 x 10(-12). The fact that these differences in individual resistance persisted, notwithstanding the repeated passage of lytic filtrates through cultures of bacteria other than those against which they were primarily active, seems to offer evidence in favor of a multiplicity of bacteriophages.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : II. EFFECT OF ALCOHOL ON THE BACTERIOPHAGE OF D'HERELLE

When bacteriophage is precipitated by alcohol at room temperature its activity rapidly and progressively decreases until it is totally destroyed, between 6 and 24 hours after exposure. If the percipitation is carried out at 7 degrees C. the destruction of lytic activity is considerably slower; measurable traces may be detected even after 4 weeks exposure to alcohol. Although the major portion of the lytic activity is found in the precipitate, the supernatant alcohol carries a measurable amount of lytic principle which remains active for several days. In all cases the residual lytic activity was found to be transmissible in series. In no instance were we able to observe the non-transmissible action ascribed by d'sHérelle to the enzyme. The persistence of traces of active principle after many weeks of exposure to alcohol at low temperature is not found to be due to the existence in the original filtrate of a fraction relatively resistant to the effect of alcohol. The inactivation of bacteriophage by alcohol seems, therefore, analogous to the alcoholic inactivation of certain enzymes and toxins.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : III. SOME OF THE FACTORS DETERMINING THE NUMBER AND SIZE OF PLAQUES OF BACTERIAL LYSIS ON AGAR

The experiments reported above confirm the fact that lytic principle is distributed in active solution in a state of indivisible units. This permits its quantitative evaluation by serial dilution, as well as by plating on agar. The latter method, however, often gives readings considerably lower than those obtained by the broth dilution method of titration. By varying the concentration of agar it has been possible to show that the discrepancy is due to adsorption of the lytic agent on agar. When the concentration of the latter is increased from 0.3 per cent to 2.5 per cent the number of plaques of lysis is reduced more than 100 times. At the same time the average size of the plaques also decreases approximately to one-tenth of the original. The size, as well as the number of plaques, has been found to depend also on the condition of the culture employed in titration. Thus, when the culture exposed to the action of lytic agent is composed of young susceptible bacteria, the greater the concentration of bacteria, the smaller the plaques. When the culture is composed partly of young and partly of old susceptible bacteria, both the size and the number of the plaques are diminished with the increase in the relative concentration of old bacteria. On the other hand, presence in the culture of resistant bacteria does not affect either the size or the number of the plaques so long as the relative concentration of susceptible bacteria in the culture is sufficient to allow formation of them. The plaques appearing in the presence of a high concentration of resistant variants in the culture are relatively indistinct owing to overgrowth. Under carefully controlled conditions the size of plaques is found to be determined by the character of the lytic filtrate. Thus in the case of lytic agents which act upon more than one bacterial species the size of the plaques remains constant, irrespective of the bacterial substratum used for the production of the active filtrate.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : I. IS THE LYTIC PRINCIPLE VOLATILE?

The lytic principle concerned in the phenomenon of transmissible lysis is not volatile. The results which have been taken to indicate volatility are, in our opinion, to be attributed to the transfer to the distillate of minute droplets of the original active filtrate.

[Perinatal herpes infection. Clinical aspects--therapy--follow-up]

Herpes simplex virus may cause serious infections in neonates. In case of foetal infection in the first trimenon, abortions, stillbirth, prematurity, intrauterine growth retardation (not obligatory) and various malformations may result. Neonatal HSV infection is mostly the consequence of intrapartum virus acquisition during passage through the birth canal. The infection is mostly localised on the skin, at the eyes or the mouth or disseminated with or without HSV meningoencephalitis. It is difficult to establish the diagnosis, because neonatal herpes disease in the early stage is not easy to distinguish from other diseases in the newborn such as RDS, NEC or ICH. Antiviral therapy with aciclovir is the treatment of choice and seems to improve the outcome of neonatal herpes. Prognosis depends on early therapy. Treatment should be initiated in relation to clinical findings, because available diagnostic techniques do not always permit an early detection of the disease.

[The status of biological risk factors and the optimality concept in diagnosis of early childhood developmental disorders]

In a prospective study the psychomotor development up to the end of the second year of life of 409 preterm and term newborn infants was examined in order to identify which optimality score might be associated with disturbances of normal childlike development. Significant connections between 24 and 55 risk factors and the mortality could be demonstrated, but only 3 factors (sex, apgar, acidosis) exert influence on psychomotor development. The risk loading of the collective was high, not one of the children showed an optimal score. Decreased patients possessed a stronger reduced optimality than survivors. The optimality concept is not suitable for the prediction of later disturbed development of children, because the items are unspecific. The marker of hypoxia, the erythrocytic-density-test, as well as the neuron-specific enolase showed better diagnostic values than the optimality concept.

[Psychomotor development of children at risk with special reference to prenatal, intrapartum and postnatal hypoxia]

In a prospective study the psychomotor development of an unselected collective of high risk newborn infants up to the end of the second year of life was examined. The proof of hypoxia was performed with the erythrocytic density test (EDT). The value of EDT showed a decline with the age of life, and it was independent of gestational age or of birthweight only at the first point of determination (cord blood, first or second day of life). Significant connections between the level of light red blood cells and the children's development could not be demonstrated, although the probability to develop psychomotor disabilities increased in the newborn with a positive value of EDT. The diagnostic value of EDT showed the best results for intrapartum and postnatal hypoxia. The highest specificity was calculated with 38.0%, if the sensitivity is 80.0%. In conclusion of these results it's not to be recommended to use the EDT alone for the prediction of individual prognosis of children.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : X. TOXIN PRODUCTION BY NORMAL AND BY PHAGE-RESISTANT SHIGA DYSENTERY BACILLI

1. The production of exotoxin and of endotoxin by normal Shiga dysentery bacilli and by strains resistant to Laudman phage was found to be the same. 2. The presence of phage did not alter toxin production by the resistant organism.

STUDIES ON THE BACTERIOPHAGE OF D'HERELLE

In VoL xliv, 5, page 614, the third column in Section A of Protocol V should show the death of all of the mice. Two died within 24 hours, two within 48 hours, and the last within 72 hours. The appended diagram giving the correction for this column can be pasted in place on the original protocol.

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STUDIES ON THE BACTERIOPHAGE OF D'HERELLE : V. EFFECT OF ELECTROLYTES ON THE RATE OF INACTIVATION OF BACTERIOPHAGE BY ALCOHOL

Addition of neutral salts to the lytic filtrate results in an increased rate of inactivation of the latter when alcohol is added to it. This effect of salts is the more marked the higher the valency of the cation. Conversely, removal by dialysis of salts originally present in the lytic filtrate tends to render lytic agent less sensitive to alcohol. Restitution of the original salt content to the dialyzed filtrate tends to bring the sensitiveness to alcohol in the dialyzed filtrate to the level of the non-dialyzed control. It appears, therefore, that inactivation of the lytic agent by alcohol depends directly on the rate of precipitation of the coagulable constituents of the medium, and is not the result of a direct toxic action of alcohol on "bacteriophagum intestinale." Considered in association with our earlier findings, these results speak in favor of the chemical nature of the agent of transmissible lysis.