Ranibizumab versus Bevacizumab to Treat Neovascular Age-related Macular Degeneration: One-Year Findings from the IVAN Randomized Trial.

Purpose
To compare the efficacy and safety of ranibizumab and bevacizumab intravitreal injections to treat neovascular age-related macular degeneration (nAMD).

Design
Multicenter, noninferiority factorial trial with equal allocation to groups. The noninferiority limit was 3.5 letters. This trial is registered (ISRCTN92166560).

Participants
People >50 years of age with untreated nAMD in the study eye who read =25 letters on the Early Treatment Diabetic Retinopathy Study chart.

Methods
We randomized participants to 4 groups: ranibizumab or bevacizumab, given either every month (continuous) or as needed (discontinuous), with monthly review.

Main Outcome Measures
The primary outcome is at 2 years; this paper reports a prespecified interim analysis at 1 year. The primary efficacy and safety outcome measures are distance visual acuity and arteriothrombotic events or heart failure. Other outcome measures are health-related quality of life, contrast sensitivity, near visual acuity, reading index, lesion morphology, serum vascular endothelial growth factor (VEGF) levels, and costs.

Results
Between March 27, 2008 and October 15, 2010, we randomized and treated 610 participants. One year after randomization, the comparison between bevacizumab and ranibizumab was inconclusive (bevacizumab minus ranibizumab -1.99 letters, 95% confidence interval [CI], -4.04 to 0.06). Discontinuous treatment was equivalent to continuous treatment (discontinuous minus continuous -0.35 letters; 95% CI, -2.40 to 1.70). Foveal total thickness did not differ by drug, but was 9% less with continuous treatment (geometric mean ratio [GMR], 0.91; 95% CI, 0.86 to 0.97; P = 0.005). Fewer participants receiving bevacizumab had an arteriothrombotic event or heart failure (odds ratio [OR], 0.23; 95% CI, 0.05 to 1.07; P = 0.03). There was no difference between drugs in the proportion experiencing a serious systemic adverse event (OR, 1.35; 95% CI, 0.80 to 2.27; P = 0.25). Serum VEGF was lower with bevacizumab (GMR, 0.47; 95% CI, 0.41 to 0.54; P<0.0001) and higher with discontinuous treatment (GMR, 1.23; 95% CI, 1.07 to 1.42; P = 0.004). Continuous and discontinuous treatment costs were £9656 and £6398 per patient per year for ranibizumab and £1654 and £1509 for bevacizumab; bevacizumab was less costly for both treatment regimens (P<0.0001).

Conclusions
The comparison of visual acuity at 1 year between bevacizumab and ranibizumab was inconclusive. Visual acuities with continuous and discontinuous treatment were equivalent. Other outcomes are consistent with the drugs and treatment regimens having similar efficacy and safety.

Financial Disclosure(s)
Proprietary or commercial disclosures may be found after the references.

Korean Parental Beliefs About ELT From the Perspective of Teachers

In South Korea, as in many other parts of the world, children begin learning English when they are very young. Korean parents want their children to learn English as quickly as possible and often make heavy financial and other investments in their children’s English language education. English language teachers of school-age learners in Korea often feel pressure and in some cases criticism from parents regarding English language instruction. This article reports the results of a study designed to begin examining the perceptions that Korean parents hold regarding English language instruction. It illustrates how some of their beliefs reflect the latest language teaching research, whereas others are more indicative of traditional Korean belief systems, educational approaches, and methodologies.

More equitable systems for allocating general practice deprivation payments:financial consequences

The allocation of general practitioner (GP) deprivation payments has been a controversial topic since they were first proposed. It has recently been suggested that the current system could be made more equitable if the payments were allocated at enumeration districts and if there was a more graded relationship between Jarman score and funding. However, the implications of these changes on the distribution of deprivation payments have not been worked out.

Handwritten undergraduate case reports

Background: This article describes a 'back to the future' approach to case 'write-ups', with medical students producing handwritten instead of word-processed case reports during their clinical placements. Word-processed reports had been found to have a number of drawbacks, including the inappropriate use of 'cutting and pasting', undue length and lack of focus. Method: We developed a template to be completed by hand, based on the hospital 'clerking-in process', and matched this to a new assessment proforma. An electronic survey was conducted of both students and assessors after the first year of operation to evaluate impact and utility. Results: The new template was well received by both students and assessors. Most students said they preferred handwriting the case reports (55.6%), although a significant proportion (44.4%) preferred the word processor. Many commented that the template enabled them to effectively learn the structure of a case history and to improve their history-taking skills. Most assessors who had previously marked case reports felt the new system represented an improvement. The average time spent marking each report fell from 23.56 to 16.38minutes using the new proforma. Discussion: Free text comments from the survey have led to the development of a more flexible case report template better suited to certain specialties (e.g. dermatology). This is an evolving process and there will be opportunities for further adaptation as electronic medical records become more common in hospital. © Blackwell Publishing Ltd 2012.

Interlocking directorates and conflicts of interest: The Rotterdamsche Bankvereeniging, Müller & Co. and the Dutch financial crisis of the 1920s

How can interlocking directorates cause financial instability for universal banks? A detailed history of the Rotterdamsche Bankvereeninging in the 1920s answers this question in a case study. This large commercial bank adopted a new German-style universal banking business model from the early 1910s, sharing directors with the firms it financed as a means of controlling its interests. Then, in 1924, it required assistance from the Dutch state in order to survive a bank run brought on by public concerns over its close ties with Müller & Co., a trading conglomerate that suffered badly in the economic downturn of the early 1920s. Using a new narrative history combined with an interpretive model, this article shows how the interlocking directorates between the bank and this major client, and in particular the direction of influence of these interlocks, resulted in a conflict of interest that could not be easily overcome.