Strengths and weaknesses of 'real-world' studies involving non-vitamin K antagonist oral anticoagulants.

Randomised controlled trials (RCTs) provide the reference standard for comparing the efficacy of one therapy or intervention with another. However, RCTs have restrictive inclusion and exclusion criteria; thus, they are not fully representative of an unselected real-world population. Real-world evidence (RWE) studies encompass a wide range of research methodologies and data sources and can be broadly categorised as non-interventional studies, patient registries, claims database studies, patient surveys and electronic health record studies. If appropriately designed, RWE studies include a patient population that is far more representative of unselected patient populations than those of RCTs, but they do not provide a robust basis for comparing treatment strategies. RWE studies can have very large sample sizes, can provide information on treatments in patient groups that are usually excluded from RCTs, are generally less expensive and quicker than RCTs, and can assess a broad range of outcomes. Limitations of RWE studies can include low internal validity, lack of quality control surrounding data collection and susceptibility to multiple sources of bias for comparing outcomes. RWE studies can complement the findings from RCTs by providing valuable information on treatment practices and patient characteristics among unselected patients. This information is necessary to guide treatment decisions and for reimbursement and payment decisions. RWE studies have been extensively applied in the postmarketing approval assessment of non-vitamin K antagonist oral anticoagulants since 2010. However, the benefits, costs, limitations and methodological challenges associated with the different types of RWE must be considered carefully when interpreting the findings

Progressive multiple sclerosis: Prospects for disease therapy, repair, and restoration of function

Multiple sclerosis is a major cause of neurological disability, which accrues predominantly during progressive forms of the disease. Although development of multifocal inflammatory lesions is the underlying pathological process in relapsing-remitting multiple sclerosis, the gradual accumulation of disability that characterises progressive multiple sclerosis seems to result more from diffuse immune mechanisms and neurodegeneration. As a result, the 14 anti-inflammatory drugs that have regulatory approval for treatment of relapsing-remitting multiple sclerosis have little or no efficacy in progressive multiple sclerosis without inflammatory lesion activity. Effective therapies for progressive multiple sclerosis that prevent worsening, reverse damage, and restore function are a major unmet need. In this Series paper we summarise the current status of therapy for progressive multiple sclerosis and outline prospects for the future

Landscape of MS patient cohorts and registries: recommendations for maximizing impact

BACKGROUND: There is a growing number of cohorts and registries collecting phenotypic and genotypic data from groups of multiple sclerosis patients. Improved awareness and better coordination of these efforts is needed. OBJECTIVE: The purpose of this report is to provide a global landscape of the major longitudinal MS patient data collection efforts and share recommendations for increasing their impact. METHODS: A workshop that included over 50 MS research and clinical experts from both academia and industry was convened to evaluate how current and future MS cohorts could be better used to provide answers to urgent questions about progressive MS. RESULTS: The landscape analysis revealed a significant number of largely uncoordinated parallel studies. Strategic oversight and direction is needed to streamline and leverage existing and future efforts. A number of recommendations for enhancing these efforts were developed. CONCLUSIONS: Better coordination, increased leverage of evolving technology, cohort designs that focus on the most important unanswered questions, improved access, and more sustained funding will be needed to close the gaps in our understanding of progressive MS and accelerate the development of effective therapies

Integrated population modelling reveals a perceived source to be a cryptic sink

This is the final version of the article. Available from the publisher via the DOI in this record.Demographic links among fragmented populations are commonly studied as source-sink dynamics, whereby source populations exhibit net recruitment and net emigration, while sinks suffer net mortality but enjoy net immigration. It is commonly assumed that large, persistent aggregations of individuals must be sources, but this ignores the possibility that they are sinks instead, buoyed demographically by immigration. We tested this assumption using Bayesian integrated population modelling of Greenland white-fronted geese (Anser albifrons flavirostris) at their largest wintering site (Wexford, Ireland), combining capture-mark-recapture, census and recruitment data collected from 1982 to 2010. Management for this subspecies occurs largely on wintering areas; thus, study of source-sink dynamics of discrete regular wintering units provides unprecedented insights into population regulation and enables identification of likely processes influencing population dynamics at Wexford and among 70 other Greenland white-fronted goose wintering subpopulations. Using results from integrated population modelling, we parameterized an age-structured population projection matrix to determine the contribution of movement rates (emigration and immigration), recruitment and mortality to the dynamics of the Wexford subpopulation. Survival estimates for juvenile and adult birds at Wexford and adult birds elsewhere fluctuated over the 29-year study period, but were not identifiably different. However, per capita recruitment rates at Wexford in later years (post-1995) were identifiably lower than in earlier years (pre-1995). The observed persistence of the Wexford subpopulation was only possible with high rates of immigration, which exceeded emigration in each year. Thus, despite its apparent stability, Wexford has functioned as a sink over the entire study period. These results demonstrate that even large subpopulations can potentially be sinks, and that movement dynamics (e.g. immigration) among winters can dramatically obscure key processes driving subpopulation size. Further, novel population models which integrate capture-mark-recapture, census and recruitment data are essential to correctly ascribing source-sink status and accurately informing development of site-safeguard networks.This research was funded through a joint PhD studentship to M.D.W. from the Wildfowl & Wetlands Trust and the University of Exeter, and through a NERC grant (NE/L007770/1) to D.J.

Should I stay or should I go? Fitness costs and benefits of prolonged parent-offspring and sibling-sibling associations in an Arctic-nesting goose population.

This is the final version of the article. Available from the publisher via the DOI in this record.Theory predicts persistence of long-term family relationships in vertebrates will occur until perceived fitness costs exceed benefits to either parents or offspring. We examined whether increased breeding probability and survival were associated with prolonged parent-offspring and sibling-sibling relationships in a long-lived Arctic migrant herbivore, the Greenland white-fronted goose (Anser albifrons flavirostris). Although offspring associated with parents for 1-13 years, 79 % of these associations lasted two or less years. Only 65 (9.9 %) of the 656 marked offspring bred once in their lifetime, and just 16 (2.4 %) bred twice or more. The probability of birds with siblings breeding successfully in a subsequent year was credibly greater than that of independent birds at ages 5, 6, and 7. Survival of offspring with parents was credibly greater than that of independent/nonbreeder birds at all possible ages (i.e., ages 2-7+). A cost-benefit matrix model utilizing breeding and survival probabilities showed that staying with family groups was favored over leaving until age 3, after which there were no credible differences between staying and leaving strategies until the oldest ages, when leaving family groups was favored. Thus, most birds in this study either departed family groups early (e.g., at age 2, when the "stay" strategy was favored) or as predicted by our cost-benefit model (i.e., at age 3). Although extended family associations are a feature of this population, we contend that the survival benefits are not sufficient enough to yield clear fitness benefits, and associations only persist because parents and offspring mutually benefit from their persistence.This research was funded through a joint PhD studentship from the Wildfowl & Wetlands Trust and the University of Exeter undertaken by MDW

Rigorous 3D change determination in Antarctic Peninsula glaciers from stereo WorldView-2 and archival aerial imagery

This paper presents detailed elevation and volume analysis of 16 individual glaciers, grouped at four locations, spread across the Antarctic Peninsula (AP). The study makes use of newly available WorldView-2 satellite stereo imagery to exploit the previously untapped value of archival stereo aerial photography. High resolution photogrammetric digital elevation models (DEMs) are derived to determine three-dimensional glacier change over an unprecedented time span of six decades with an unparalleled mean areal coverage of 82 % per glacier. The use of an in-house robust surface matching algorithm ensured rigorous alignment of the DEMs to overcome inherent problems associated with processing archival photography, most notably the identification and correction of scale error in some datasets. The analysis provides insight into one of the most challenging and data-scarce areas on the planet by expanding the spatial extent north of the AP to include previously un-studied glaciers located in the South Shetland Islands. 81 % of glaciers studied showed considerable loss of volume over the period of record. The mean annual mass loss for all glaciers yielded 0.24 \ub1 0.08 m.w.e. per year, with a maximum mass loss of up to 62 m.w.e. and frontal retreat exceeding 2.2 km for Stadium Glacier, located furthest north on Elephant Island. Observed volumetric loss was broadly, though not always, correlated with frontal retreat. The combined mass balance of all 16 glaciers yielded -1.862 \ub1 0.006 Gt, which corresponds to -0.005 mm sea level equivalent (SLE) over the 57 year observation period

Outbreak of tropical rat mite (Ornithonyssus bacoti) dermatitis in a home for disabled persons

Five mentally handicapped individuals living in a home for disabled persons in Southern Germany were seen in our outpatient department with pruritic, red papules predominantly located in groups on the upper extremities, neck, upper trunk and face. Over several weeks 40 inhabitants and 5 caretakers were affected by the same rash. Inspection of their home and the sheds nearby disclosed infestation with rat populations and mites. Finally the diagnosis of tropical rat mite dermatitis was made by the identification of the arthropod Ornithonyssus bacoti or so-called tropical rat mite. The patients were treated with topical corticosteroids and antihistamines. After elimination of the rats and disinfection of the rooms by a professional exterminator no new cases of rat mite dermatitis occurred. The tropical rat mite is an external parasite occurring on rats, mice, gerbils, hamsters and various other small mammals. When the principal animal host is not available, human beings can become the victim of mite infestation. Copyright (c) 2007 S. Karger AG, Base

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation.

Importance: Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy. Objective: To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone. Design, Setting, and Participants: Prospective cohort study of the GARFIELD-AF registry, an international, multicenter, observational study of adults aged 18 years and older with recently diagnosed nonvalvular atrial fibrillation and at least 1 risk factor for stroke enrolled between March 2010 and August 2016. Data were extracted for analysis in October 2017 and analyzed from April 2018 to June 2019. Exposure: Participants received either OAC plus AP or OAC alone. Main Outcomes and Measures: Clinical outcomes were measured over 3 and 12 months. Outcomes were adjusted for 40 covariates, including baseline conditions and medications. Results: A total of 24 436 patients (13 438 [55.0%] male; median [interquartile range] age, 71 [64-78] years) were analyzed. Among eligible patients, those receiving OAC plus AP therapy had a greater prevalence of cardiovascular indications for AP, including acute coronary syndromes (22.0% vs 4.3%), coronary artery disease (39.1% vs 9.8%), and carotid occlusive disease (4.8% vs 2.0%). Over 1 year, patients treated with OAC plus AP had significantly higher incidence rates of stroke (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.01-2.20) and any bleeding event (aHR, 1.41; 95% CI, 1.17-1.70) than those treated with OAC alone. These patients did not show evidence of reduced all-cause mortality (aHR, 1.22; 95% CI, 0.98-1.51). Risk of acute coronary syndrome was not reduced in patients taking OAC plus AP compared with OAC alone (aHR, 1.16; 95% CI, 0.70-1.94). Patients treated with OAC plus AP also had higher rates of all clinical outcomes than those treated with OAC alone over the short term (3 months). Conclusions and Relevance: This study challenges the practice of coprescribing OAC plus AP unless there is a clear indication for adding AP to OAC therapy in newly diagnosed atrial fibrillation

Flavour physics from an approximate U(2)^3 symmetry

The quark sector of the Standard Model exhibits an approximate U(2)^3 flavour symmetry. This symmetry, broken in specific directions dictated by minimality, can explain the success of the Cabibbo-Kobayashi-Maskawa picture of flavour mixing and CP violation, confirmed by the data so far, while allowing for observable deviations from it, as expected in most models of ElectroWeak Symmetry Breaking. Building on previous work in the specific context of supersymmetry, we analyze the expected effects and we quantify the current bounds in a general Effective Field Theory framework. As a further relevant example we then show how the U(2)^3 symmetry and its breaking can be implemented in a generic composite Higgs model and we make a first analysis of its peculiar consequences. We also discuss how some partial extension of U(2)^3 to the lepton sector can arise, both in general and in composite Higgs models. An optimistic though conceivable interpretation of the considerations developed in this paper gives reasons to think that new physics searches in the flavour sector may be about to explore an interesting realm of phenomena.Comment: 29 pages, 5 figure