Alexandru Răzvan

Vincent Radu

Paolo Costalat

Imad Machi

Cyril Derraz

Pierre Dargazanli

Federico Meyer

Cagnazzo

Răzvan Alexandru Radu

Vincent Costalat

Paolo Machi

Imad Derraz

Cyril Dargazanli

Pierre Meyer

Federico Cagnazzo

Thrombectomy for a basilar artery occlusion in a 2-year-old child: A focus on anatomical and technical aspects

Keywords: Pediatric stroke, cerebrovascular diameters, common femoral artery diameters, device compatibility, thrombectomy

Thrombectomy for a basilar artery occlusion in a 2-yearold child: A focus on anatomical and technical aspects Introduction

Endovascular treatment (EVT) for acute ischemic stroke is currently one of the main pillars of reperfusion treatment in adult patients with large vessel occlusion.1,2 Notably, large vessel occlusion is also present in nearly one-quarter of pediatric stroke patients.3 However, current pediatric guidelines do not provide strong recommendations for thrombectomy, mainly due to a lack of evidence, and they even state that EVT should probably be reserved for "larger children due to concerns about introducing catheters into small groin-and cerebral arteries". [START_REF] Ferriero | Management of stroke in neonates and children: a scientific statement From the American Heart Association/American Stroke Association[END_REF] Nevertheless, despite the lack of high-quality evidence, some retrospective pediatric case series have shown encouraging clinical and radiological results of mechanical thrombectomy in the pediatric population. In a single-arm, retrospective study including 73 pediatric stroke patients treated with EVT, a favorable neurological outcome (modified Rankin Scale score of 0-2) was obtained in 87% of cases.5 Similarly, a recent meta-analysis demonstrated favorable outcomes in 90.6% of 113 pediatric stroke patients treated with EVT.6 While these high rates of a positive outcome vastly outperform results obtained in adult patients and are probably due to selection bias, a recent prospective cohort study identified a good functional outcome at three months in 50% of EVT-treated children compared to 27% in children who were offered conservative treatment.3

The most significant two pediatric EVT series mentioned above reported less than 30 cases of thrombectomy in patients ≤6 years old, with even lower numbers in younger children. [START_REF] Sporns | Feasibility, safety, and outcome of endovascular recanalization in childhood stroke: the Save ChildS Study[END_REF][START_REF] Bhatia | Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series[END_REF] To complement the small number of cases of EVT described in children ≤6 years old, as well as the position of the American Heart Association/American Stroke Association guidelines regarding this topic,4 we describe a case of a 2-year-old child with a basilar occlusion treated with EVT. Following a thorough review of the published literature reporting on the development of arterial diameters by age groups, we provide also detailed tables comparing the size evolution of femoral and cerebral vessels and the diameter of the most commonly used neuroendovascular materials.7-9

Case report

A 2-year-old, male child with normal development and no past medical history presented an episode of loss of balance and altered consciousness at 10h00, which was initially mistakenly interpreted as a seizure by the emergency medical team. He was weighing 15 kg and his height was 92 cm. He was hemodynamically stable, afebrile and was brought to a primary care center.

The initial physical examination showed intermittent left-sided hypertonia, intermittent clonic movements, right-sided paresis, symmetric pupils with diminished right-sided photo-motor reflex and flexor plantar reflexes and the pediatric NIHSS was coted at 29 points. The initial non-contrast-enhanced computed tomography (CT) scan was interpreted as normal and the blood work-up was unremarkable. A suspicion of seizure was raised, and he was treated with clonazepam. Following a further episode of impaired consciousness, he was intubated, and brain magnetic resonance imaging (MRI) was performed. The MRI performed at 13h06 showed DWI-positive cerebellum and thalamic lesions, together with a basilar artery (BA) occlusion.

The comprehensive stroke center was alerted at 14h30, and the patient arrived 3 h later. Given the young age of the patient and the high chance of important disability associated with medical treatment alone in basilar occlusion in children, a decision was taken to undergo mechanical thrombectomy if a repeated MRI did not show irreversible pontine lesions. The repeated MRI (Figure 1 A, B) showed stability of the ischemic lesions and occlusion so EVT was tempted. Symptom onset to groin puncture time was 8 h. The common femoral artery (CFA) was explored under echo and measured approximately 4 mm in diameter. A 6-Fr 7 cm radial introducer (Radiofocus, Terumo Europe N.V., Leuven, Belgium) was placed into the right CFA. Access to the left vertebral artery was gained using a 6-Fr 95 cm guide catheter (Chaperon MP2, Microvention, Tustin, CA, USA) (Figure 1C). Once cervical access was secured, a 5-Fr 125 cm distal access catheter (Sophia, Microvention, Tustin, CA, USA) was advanced on a 0.014'' 200 cm guidewire (Synchro Standard, Stryker, Salt Lake City, UT, USA) and a 0.017'' 150 cm microcatheter (Headway, Microvention, Tustin, CA, USA) just before the thrombus. After the first passage of manual aspiration, the BA was recanalized, but the right P1 segment was occluded by a thrombus. A second pass aspiration with a SOFIA 5-F was unsuccessful and a 3 x 20 mm pREset LITE stent retriever was combined with manual aspiration through the 5-F catheter, obtaining a complete recanalization (Figure 1D). Manual compression of the femoral puncture site was performed at the end of the procedure. The patient was transferred to the pediatric intensive care unit where he progressively recovered. At discharge, after 3 weeks, he presented a slight divergent strabismus of his right eye and a slight left-sided hemiparesis. At 3-month follow-up, the patient was fully recovered without neurological sequelae. After extensive stroke workup, which included transthoracic echocardiography with bubble contrast test, regular laboratory tests, and: antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, and anti-β2glycoprotein), protein C and S, activated protein C resistance, antithrombin III antibodies, homocysteine levels, antineutrophil cytoplasmic antibodies, anti-nuclear antibodies, complement proteins (C3, C4, CH50), immunoglobulins assay (IgG, IgA, IgM), varicella titer, genetic testing (COL4A1, COL4A2, COLGALT1, methylenetetrahydrofolate reductase, and CECR1/ADA2 genes), no stroke etiology was found. The final diagnosis was an ischemic stroke of undetermined cause. Follow-up imaging at six months showed minor sequela in the thalamus and pons (Figure 1 E,1F).

Discussion

Thrombectomy procedures in small children remain a subject of debate.4 A recent review of 11 cases of thrombectomy in children <5 years of age showed that the procedure was feasible, without significant safety concerns, and with better recanalization in the posterior circulation compared to the anterior circulation (80% vs. 43%).10 Although the median age in this series was 2.1 years, the youngest thrombectomy reported in the literature was a basilar occlusion successfully treated at 14 h after birth with two passes of a 3 mm stent retriever.11 Unlike our case, children in this age group usually do not have normal development and frequently suffer from congenital cardiac problems.10,12

Due to diagnostic challenges, the timely identification of pediatric patients suitable for reperfusion therapies is challenging. Most high-volume centers expect to perform <3 childhood thrombectomies per year, with 64% performing thrombectomies after 6 h, despite setting up pediatric stroke protocols in their hospitals. [START_REF] Harrar | Pediatric acute stroke protocols in the United States and Canada[END_REF] For example, 30% of patients included in the Save ChildS study underwent thrombectomy in the 6-24 h time window.5 In this subgroup, cerebral vasospasm was the only encountered complication. In addition, there were no symptomatic intracerebral hemorrhages and outcomes were better than in the DAWN and DEFUSE-3 trials.14 In our case, door-to-groin puncture time was achieved at least 8 h from symptom onset, and the patient had an excellent functional outcome, despite infarction already present in the mesencephalon and thalamus before thrombectomy (Figure 1A).

The main challenge of endovascular procedures in children is the size of the femoral and brain and neck arteries. Nomograms of femoral and cerebral artery diameters help to plan emergency endovascular procedures in children. Palpation techniques cannot assess the level of bifurcation of common femoral arteries in children and puncturing below the bifurcation point raises the risk of inadvertent complications. For this reason, echo-guided puncture should strongly be considered in this population. [START_REF] Phillips | Procedural complications during congenital cardiac catheterization[END_REF] As for femoral artery diameters, a detailed knowledge of expected cerebral artery diameter sizes is crucial to safely perform thrombectomies in children and a personalized measurement of artery size can be done on available pre-procedure, diagnostic imaging (time of-flight MRI or CT angiography). However, knowledge of the evolution of the cerebral arterial diameter by age may help in the decision-making process in order to assess the feasibility and safety of the endovascular procedure based on patient age. In contrast to the iliac artery, which reaches 60% of the average adult diameter by 2 years of age, all segments of the internal carotid artery (ICA) circulation already reach 81-99% of the adult diameter by 2 years, with the middle cerebral artery size attaining 87% of the adult size in the first 6 months of life.9 Moreover, cerebral vessel diameter changes minimally after 5 years of age. Similar to the anterior circulation, the BA reaches the average adult diameter by 2 years of age. It is expected to measure around 2 mm at 1 year of age, thereby capable of accommodating smaller intracranial aspiration catheters and stent retrievers. [START_REF] He | Rule of 5: angiographic diameters of cervicocerebral arteries in children and compatibility with adult neurointerventional devices[END_REF] In Figure 3 provides BA and Figure 4 provides MCA, ICA diameters by age and their compatibility with currently used catheters. In general, up to 1 year, the ICA may accommodate all guiding catheters <2.2 mm outer diameter. At 2 years of age, the average diameter of the ICA is >3 mm and a larger catheter, such as the NeuronMax (Penumbra Inc, Alameda, CA, USA), can be safely used. The MCA and BA can be safely catheterized with a 5-Fr distal catheter until 1 year of age, while at 2 years, 6-Fr catheters are allowed.

Data on artery size and device compatibility are limited to a few published series and our work provides additional information for the choice of the endovascular material. However, given the apparent safety and significant functional gains expected from EVT in childhood stroke, thrombectomy should not be contraindicated, considering that most of the available neurocatheters are compatibles with the arterial diameter in the pediatric population.

In conclusion, our experience brings additional insights about the compatibility of endovascular catheters to access arterial vessels in pediatric patients presenting with a stroke associated with large vessel occlusion. Knowledge of age-related arterial diameters is crucial to select the most appropriate material in pediatric stroke cases.

Figure 1 .

 1 Figure 1. Magnetic resonance imaging (MRI) and digital substraction angiography (DSA) of our index case. A. MRI imaging showing decreased apparent diffusion coefficient in the mesencephalon; B. lateral projection DSA showing basilar occlusion with associated arterial diameters; C. frontal DSA after the first passage. D. final frontal DSA showing a small vasospasm in the right posterior cerebral artery (PCA), turbulence due to competitive flow coming from the posterior communicating artery in the left PCA, and persistent occlusion of the right superior cerebellar artery.

Figure 2 . 17 Figure 3 .

 2173 Figure 2. Expected diameters of the common femoral artery based on age and introducer compatibility adapted after references 7-8,16-17

Figure 4 .

 4 Figure 4. Expected diameters of the internal carotid and middle cerebral artery based on age and catheter compatibility adapted after references9,19

  The risk of femoral artery complications increases with punctures in arteries less than 3 mm. Based on currently available normograms, this diameter is attained in most patients by 1 year of age.16 Moreover, femoral artery diameters are strongly correlated with height, and children over 110 cm usually have a median diameter greater than 3 mm.8 Based on currently available data, we have produced a chart to show the compatibility between different catheters and introducers and common femoral artery diameters based on age.7,8,17 Figure2shows that at 5 years of age, the mean CFA diameter is very close to the adult diameter.[START_REF] Sandgren | The diameter of the common femoral artery in healthy human: Influence of sex, age, and body size[END_REF] In general, until the age of 6 months, the average CFA diameter is approximately 2.3 mm and a 4-Fr radial introducer should be preferred. At 1 year of age, an average CFA may safely accommodate a 6-Fr introducer.

Funding.

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors' contributions.

All authors made substantial contributions to the conception, design of the study, acquisition or analysis, and interpretation of the data.

Declaration of conflicting interests.

All authors declare no conflicts of interest.

Ethical approval.

This work did not require ethical approval. Written informed consent was obtained from the parents of the patient presented herein.


est destinée au dépôt

Bee and bee product samples for analysis

Marie-Pierre Chauzat, Philippe Bulet

To cite this version:

Marie-Pierre Chauzat, Philippe Bulet. Bee and bee product samples for analysis. ANSES. 2020. hal-04467599


Perspectives Yeon

Joo Lee

Antonio García Muñoz

Atsushi Yamazaki

Eric Quémerais

Stefano Mottola

Stephan Hellmich

Thomas Granzer

Gilles Bergond

Martin Roth

Eulalia Gallego-Cano

Jean-Yves Chaufray

Rozenn Robidel

Kei Masunaga

Murat Kaplan

Orhan Erece

Ricardo Hueso

Petr Kabáth

Magdaléna Špoková

Agustín Sánchez-Lavega

Myung-Jin Kim

Valeria Mangano

Kandis-Lea Jessup

Thomas Widemann

Ko-Ichiro Sugiyama

Shigeto Watanabe

Manabu Yamada

Takehiko Satoh

Masato Nakamura

Masataka Imai

Juan Cabrera

Reflectivity of Venus's Dayside Disk During the 2020 Observation Campaign: Outcomes and Future

la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

We performed a unique Venus observation campaign to measure the disk brightness of Venus over a broad range of wavelengths in August and September 2020. The primary goal of the campaign is to investigate the absorption properties of the unknown absorber in the clouds. The secondary goal is to extract a disk mean SO2 gas abundance, whose absorption spectral feature is entangled with that of the unknown absorber at the ultraviolet (UV) wavelengths. A total of three spacecraft and six ground-based telescopes participated in this campaign, covering the 52 to 1700 nm wavelength range. After careful evaluation of the observational data, we focused on the data sets acquired by four facilities. We accomplished our primary goal by analyzing the reflectivity spectrum of the Venus disk over the 283-800 nm wavelengths. Considerable absorption is present in the 350-450 nm range, for which we retrieved the corresponding optical depth by the unknown absorber. The result shows a consistent wavelength dependence of the relative optical depth with that at low latitudes during the Venus flyby by MESSENGER in 2007 [1], which was expected because low latitudes dominate the overall disk reflectivity. Our experience obtained during this first campaign should enable us to accomplish our second goal in future campaigns, which will be introduced in our presentation.


Carole-Anne Julien

Georges Ha Van

Jocelyne M'bemba

Muriel Bourgeon

Dured Dardari

Marc Lepeut

Isabelle Dumont

Mohammed Zakarya Zemmache

Chris Serrand

Benjamin Bouillet

Mohammed Zakarya Zemmache

Ariane Sultan

Sophie Schuldiner
email: sophie.schuldiner@chu-nimes.fr.

; Epichar

Florence Baudoux

Marie Martine

Bonello Faraill

Pierre Bonnin

Florence Bouilloud

Miguel Bourgade

Marie Cazaubiel

Vaneva Chingan-Martino

Sylvaine Clavel

Enrique Da Costa Correia

Fabrice Devemy

Maud François

Sylvie Grandperret-Vauthier

Laurence Kessler

Amal Lemoine

Jacques Martini

Arnaud Monier

Myriam Moret

Marie Muller

Vincent Rigalleau

Geneviève Crouzeix

Nathalie Vigier-Simorre

Julien Vouillarmet

Real-world treatment patterns and diagnosis of charcot foot in franco-belgian diabetic

Keywords: Belgium, Charcot foot, Diabetic foot, France, Magnetic resonance imaging, Offloading

Introduction

Charcot Neuroosteoarthropathy (CN) is a severe complication mainly in diabetic patients that arises secondary to severe peripheral neuropathy, with major inflammation leading to progressive bone destruction of the foot or ankle [START_REF] Rogers | The Charcot foot in diabetes[END_REF]. The origin of this process is not well understood.

CN has an acute and a chronic phase. The acute phase is characterized by the sudden onset of an erythematous, unilateral, slightly painful edema of the foot or ankle with an increase in skin temperature greater than 2 °C compared to the contralateral foot. The edema may regress rapidly after discontinuation of weight-bearing and recur when weight-bearing is resumed [START_REF] Milne | Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review[END_REF][START_REF] Rogers | The Charcotfoot in diabetes[END_REF][START_REF] Vopat | Initial diagnosis and management for acute charcot neuroarthropathy[END_REF][START_REF] Fontaine | Current concepts of Charcot foot in diabetic patients[END_REF]. In some cases, the acute phase is triggered by foot minor trauma, foot surgery, an infection, or a foot ulceration. Without optimal treatment, osteoarticular lysis can develop, leading to multiple fractures or spontaneous dislocation. Initially, the loss of sensitivity may hint at a peripheral neuropathy and a discrete inflammatory syndrome without a clear increase in leukocytosis or CRP found in blood samples. To confirm the diagnosis, Magnetic Resonance Imaging (MRI) of the foot and ankle is the reference examination because it is the most sensitive (between 77 and 100%). It can generally show bone marrow edema and nondisplaced fractures, while foot radiographies may appear normal at a very early stage [START_REF] Chantelau | Is the Eichenholtz classification still valid for the diabetic Charcot foot?[END_REF].

The primary treatment for acute Charcot foot is early immobilization and offloading of the affected foot with a non-removable Total Contact Cast until abatement of inflammation (difference of temperature less than 2 °C between the feet). This should be started as soon as possible to reduce the risk of subsequent fractures and deformities. Inappropriate management leads to a gradual destruction of the foot architecture, abnormality of the morphostatics of the foot and an increased risk of foot ulceration. There is no consensus on whether to allow weight-bearing or the duration of immobilization. The foot can recover with optimal treatment, but delayed diagnosis and treatment is frequent, leading to aggravated chronic phase.

However, although CN is a major complication of diabetes, data about diagnosis and treatment are sparse and frequently retrospective, without consensus. [START_REF] Frykberg | Epidemiology of the Charcot foot[END_REF][START_REF] Griffiths | Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study[END_REF][START_REF] Dixon | A retrospective audit of the characteristics and treatment outcomes in patients with diabetes-related charcot neuropathic osteoarthropathy[END_REF][START_REF] Hingsammer | Correlation of systemic inflammatory markers with radiographic stages of charcot osteoarthropathy[END_REF][START_REF] Gazis | Mortality in patients with diabetic neuropathic osteoarthropathy (Charcot foot)[END_REF]. The prevalence of CN varies between 0.1 and 0.4% in the general diabetic population to 12% in diabetes mellitus with long duration, rising to 18% after simultaneous kidney-pancreas transplantation [START_REF] Matricali | High rate of charcot foot attacks early after simultaneous pancreas-kidney transplantation[END_REF][START_REF] Anthony | Development of charcot neuroarthropathy in diabetic patients who received kidney or kidney-pancreas transplants[END_REF][START_REF] Barrado | Charcot neuroarthropathy after simultaneous pancreaskidney transplantation: risk factors, prevalence, and outcome[END_REF]. The annual incidence of CN is less than 1% per year in the diabetic population [START_REF] Jeffcoate | Charcot foot syndrome[END_REF]. Recently, in the Danish National Patient Register, a prevalence of 0.56% for hospitalized patients with diabetes was reported from 1995 to 2018 and an incidence rate of 7.4 per 10,000 person-years [START_REF] Svendsen | How common is the rare charcot foot in patients with diabetes?[END_REF]. As CN is rare, clinician knowledge of this complication is limited, leading to non-or delayed diagnosis and treatment in about 25% of cases [START_REF] Frykberg | Epidemiology of the Charcot foot[END_REF]. The midfoot is preferentially affected, leading to the "rocker bottom foot" with collapse of the midfoot [START_REF] Fabrin | Long-term follow-up in diabetic Charcot feet with spontaneous onset[END_REF][START_REF] Larsen | Incidence and management of ulcers in diabetic Charcot feet[END_REF][START_REF] Boyko | A prospective study of risk factors for diabetic foot ulcer the seattle diabetic foot study[END_REF][START_REF] Saltzman | How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet?[END_REF]. The incidence of foot ulcer varies between 10 to 17% annually, and is 3.5fourfold greater in diabetic patients with CN compared with those without CN [START_REF] Fabrin | Long-term follow-up in diabetic Charcot feet with spontaneous onset[END_REF][START_REF] Larsen | Incidence and management of ulcers in diabetic Charcot feet[END_REF][START_REF] Boyko | A prospective study of risk factors for diabetic foot ulcer the seattle diabetic foot study[END_REF][START_REF] Saltzman | How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet?[END_REF]. Foot ulcer increases the risk of foot amputation [START_REF] Sohn | Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer[END_REF], causes deterioration in the quality of life [START_REF] Pinzur | Health-related quality of life in patients with charcot foot[END_REF] and decreases life expectancy [START_REF] Van Baal | Mortality associated with acute Charcot foot and neuropathic foot ulceration[END_REF].

The aim of this study was to evaluate the diagnostic means and management modalities of chronic and acute CN in diabetic foot centers in France and Belgium and explore the feasibility of a future registry for patients with CN.

Materials and methods

This prospective multicenter observational pilot study was conducted from 1 January 2019 to 31 December 2019. Thirty French and one Belgium hospital, reference center for diabetic foot management participated in the study. Our work was performed according to the guidelines of good clinical practice and the Declaration of Helsinki. Written informed consent was obtained from all patients before participation. The study was approved by the ethical committee (CPP Est-III, #2018-A01721-54) and registered on clinical-trials.gov (#NCT03744039).

The study population consisted of all patients with diabetes mellitus aged ≥ 18 years, with a previous diagnosis of CN admitted to hospitalization or consultation for acute or chronic CN.

No follow-up was performed.

The primary objective was to describe and analyze the diagnostic and management methods for CN in diabetic foot centers according to the clinical characteristics of patients, the clinicalradiological characteristics of acute and chronic and the discharge means used. Secondary objectives were to determine the prevalence of diabetic patients with acute and chronic CN over a 12-month period treated by each center, and to identify the diabetic foot centers offering surgical management of CN, to specify the type of procedure offered and the indications. Finally, the feasibility of creating a CN patient register was explored by asking centers whether they would be willing to participate in such a registry.

The information collected included sociodemographic data, medical history, and clinical data. Clinical and imaging methods used to investigate the CN and management of the neuropathic osteoarthropathy were recorded. Diabetes was classified into three categories: i) type 1 diabetes mellitus, ii) type 2 diabetes mellitus, iii) other, comprising secondary and glucocortico-induced diabetes. CN was classified as acute or chronic using Eichenholtz stage [START_REF] Eichenholtz | Charcot Joints[END_REF] and the Chantelau classification based on MRI when available [START_REF] Chantelau | Is the Eichenholtz classification still valid for the diabetic Charcot foot?[END_REF][START_REF] Chantelau | Evaluation of the diabetic charcot foot by MR imaging or plain radiography-an observational study[END_REF], a CN was considered as chronic if it presented more than 6 months of progression with no inflammatory sign of the foot. Neuropathy was verified by the presence or absence of suggestive symptoms/signs (paresthesia or cramps, dry skin or hyperkeratosis on the foot, foot deformities) and using the 10-g Semmes-Weinstein monofilament test, as recommended by the International Work Group of Diabetic Foot (IWGDF) [START_REF] Schaper | IWGDF Editorial Board Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update)[END_REF]. Nephropathy corresponded to a glomerular filtration rate < 60 mL/min/1.73 m 2 (modification of diet in renal disease formula). Peripheral artery disease was clinically assessed by the presence or absence of suggestive symptoms/signs (intermittent claudication and leg pain at rest, cold legs or feet, pale or bluish-looking skin), examination of foot pulses [START_REF] Hinchliffe | International Working Group on the Diabetic Foot (IWGDF) Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update)[END_REF]. This diagnosis could be completed by Doppler ultrasound, ankle-brachial pressure index (ABPI), transcutaneous oxygen pressure (TcPO2) or great-toe systolic pressure examinations.

Statistical analysis

Anonymized data were collected in RedCap. Statistical anal-yses were carried out using SAS software (Statistical Analysis System, version 9.4, SAS Institute, Cary, NC, USA). Population characteristics were expressed as means ± standard deviation (SD) or medians, using the first and third quartiles for the quantitative variables, and percentages for qualitative variables. For qualitative variables, comparisons between groups were carried out using the Chi-square test, or Fisher test when appropriate. For quantitative variables, the Stu-dent's t-test was used when distribution was Gaussian, and with the Mann-Whitney test otherwise.

A p-value < 0.05 was considered to be statistically significant.

Results

Overall, 494 patients were screened during the inclusion period. We excluded patients who were previously included and those not meeting the inclusion criteria, leaving a total of 467 participants for analysis (Fig. 1). Of the 467 patients included, 103 had acute CN and 364 had chronic CN. As 101 patients had bilateral CN (21.6%), 568 CN feet were analyzed.

Baseline characteristics of the study population

The demographic and clinical characteristics of the study population are reported in Table 1. Most patients were male (73.4%) with an average age of 62.0 ± 11.5 years, and had type 2 diabetes mellitus (79.8%) for at least ten years (87.9%).

Most patients were treated by insulin (73.3%, n = 340) with a high prevalence of microangiopathy complications (96.8%, n = 451) and a history of diabetic foot ulcer and/or amputation of lower limb (83.9%, n = 390).

Approximately 39.0% of patients recruited were already followed in a specialized center for C, while 24.5% were newly referred by an endocrinologist following a diagnosis of CN. 11.8% were newly referred by their general practitioner following a diagnosis of CN and 11.6% were self-referred following a diagnosis of CN. Finally, 9% were newly diagnosed CN cases discovered in the recruiting specialized centers. MRI data were incomplete for certain scores; 21 patients did not have Sanders classification, 20 patients had missing data for Eichenholtz classification, and 302 for Chantelau. According to the Eichenholtz classification [START_REF] Eichenholtz | Charcot Joints[END_REF], 77% were at stage 3 (chronic phase), 10.8% at stage 2 and 11.5% at stage 1 (Table 2).

Using the Chantelau MRI classification [START_REF] Chantelau | Evaluation of the diabetic charcot foot by MR imaging or plain radiography-an observational study[END_REF], 81.6% of the feet presented grade IV or V abnormalities (fracture or bone callus). Using the Sanders classification [START_REF] Sanders | Diabetic neuropathic osteoarthropathy : the Charcot foot. The high risk foot in diabetes mellitus[END_REF], the CN was mainly localized on the midfoot: the Lisfranc joint line (Sanders II) was affected in 53.7% of cases and the Chopart joint line (Sanders III) in 54.0% of cases. The forefoot (Sanders I) was affected in 14.9% of the cases, the ankle (Sanders IV) in 11.8% and the calcaneus (Sanders V) in 3.1%. At least two areas were affected simultaneously in 34.8% of cases and patients could therefore be classed into more than one Sanders group.

Acute phase of the disease

In the study population, 108 acute or subacute CN (stages 0/1 and 2 with Eichenholtz classification) were included from 103 patients (22%), with a mean age of 60.2 ± 12.2 years, and a median BMI of 30 kg/m 2. Twenty-two (21.6%) of patients in the acute group had type 1 diabetes and they had fewer complications than patients with chronic CN in terms of renal function, and macroangiopathy (p < 0.05). The absence of foot ulcer history was also significantly different between patients in acute vs chronic phase (61.8% vs 90.1%, respectively; p < 0.001) (Table 1).

Most cases had local inflammatory signs (n = 88, 81.5%), of which edema was the main symptom (n = 81, 75.0%), followed by an increase of local warmth (n = 63, 58.3%), pain (n = 55, 50.9%) and redness (37, 34.3%) (Table 3).

A triggering factor was observed in 45 cases (41.8% of acute CN) mainly due to foot trauma (n = 28, 25.9%). Vascular surgery was never recorded as a triggering factor and only 4 cases of orthopedic surgery (Table 3). Acute CN onset occurred in younger patients with type 1 than type 2 diabetes (52.5 years ± 12.3 vs 62.1 ± 10.4, respectively; p= 0.0043).

Imaging was performed in 92 acute cases (87.2%) to con-firm the diagnosis, including MRI (n = 70, 64.8%), X-ray (n = 53, 49.1%), Computed Tomography (CT) scan (n = 16, 14.8%), bone scan (n = 8, 7.4%), and Positron Emission Tomography (PET)-scan (n = 5, 4.63%). Other investigations (biology, vascular evaluation) were performed in 51 cases (47.22%) to rule out a differential diagnosis (Table 3).

Offloading was proposed in 88.9% of cases. Standard removable cast walker was most commonly prescribed (n = 39, 36.1%), followed by irremovable boot (n = 22, 20.4%), wheelchair (n = 23, 21.3%), removable custom boot (n = 7, 6.5%), temporary or permanent orthopedic shoes (n = 10, 9.3%), and canes, crutches or walker (n = 8, 7.4%).

Chronic phase of the disease

460 chronic CN were studied in 364 patients, with a mean age of 62.5 ± 11.2 years, and median BMI of. 31 kg/m 2 . The majority had type 2 diabetes (81%) for longer than 10 years. Insulin treatment was established in 74.9% of patients. Patients with chronic CN had at least two microangiopathic complications in 75% of cases, and dialysis in 10% of cases. Diabetic foot ulcer history was present in 90.1% of patients (Table 1). Specific footwear was noted in 81.5% of cases (370 patients) with custom orthopedic footwear (66.7%), medical series footwear (6.5%) or standard series footwear (5.9%).

Comparison between patients with unilateral (n = 366) and bilateral (n = 101) CN showed a significant difference in the diabetic foot ulcer history: 86% (87 patients) of bilateral CNs had a history of a trophic disorder versus 74% of unilateral CNs (271 patients), p = 0.011). No other statistical difference in the demographic and clinical characteristics was observed between the two groups (Table 4).

Presence of a diabetic foot ulcer

All stages combined, 228 patients had a diabetic foot ulcer (48.8%) during examination. A soft tissue infection was suspected and/or documented in 37.7% of cases (86 patients, 13 acute CN, 73 chronic CN), whereas a bone infection was suspected and/or documented in 33.3% of cases (76 patients, 18 acute CN, 58 chronic CN).

Surgical approach

Surgery was proposed for 123 CN (21.6%) overall, and per-formed in 73 patients (59.3%, 73/123) including 64 (87.7%) chronic CN and 9 (12.3%) acute CN. The main indications were for infection, with positive bacteriological samples (n = 26, 35.6%) and surgical correction of foot deformities (i.e. correction of static disorders of the forefoot (n = 21, 28.8%). Minor and/or major amputations represented 11 indications of surgery (15%). Eleven of the 31 centers offered surgery, all indications combined. In total, 30 (98%) of centers were willing to supply information to a diabetic foot registry.

Discussion

This multicenter study recruited a large panel of patients with CN, treated in 31 expert centers belonging to the "diabetic foot" group of the Francophone Society of Diabetes. This is one of the largest observational studies carried out on this pathology. The profile of our patients was comparable to that described in the literature. The male predominance was more pronounced in our study than in previous studies [START_REF] Van Baal | Mortality associated with acute Charcot foot and neuropathic foot ulceration[END_REF][START_REF] O'loughlin | Diabetic charcot neuroarthropathy: prevalence, demographics and outcome in a regional referral centre[END_REF][START_REF] Chaudhary | Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study[END_REF][START_REF] Leung | Charcot foot in a Hong Kong Chinese diabetic population[END_REF], which had not found an increased risk of developing CN by sex [START_REF] Frykberg | Epidemiology of the Charcot foot[END_REF][START_REF] Bergis | Coronary artery disease as an independent predictor of survival in patients with type 2 diabetes and Charcot neuro-osteoarthropathy[END_REF][START_REF] Younis | Charcot osteoarthropathy in type 2 diabetes persons presenting to specialist diabetes clinic at a tertiary care hospital[END_REF]. The average age of our population was 62.0 ± 11.5 years. However, CN was also seen in younger patients with type 1 diabetes: 22 of our patients were under 40 years old (4.7% of the population), the youngest being 26 years old. Our results indicated that onset of acute CN was earlier in subjects with type 1 versus type 2 diabetes mellitus (with a significant difference of about 10 years), in accordance with a British study from 2004 [START_REF] Petrova | Difference in presentation of charcot osteoarthropathy in type 1 compared with type 2 diabetes[END_REF].

Patients with CN generally had long-standing diabetes (for more than 10 years), most often type 2, insulin dependent and multi-complicated. Microangiopathies were by far the most frequent complications observed (96.8%). However, autonomic neuropathy was only reported in 11.1% of patients. This number was probably underestimated due to an insufficient diagnosis. Most patients had a podiatric his-tory (n = 390, 83.9%). In addition, 9% of CN were incidentally discovered, confirming the lack of knowledge of this pathology by clinicians.

According to our results, 19% of patients presented an acute CN, of which less than 1% were at the in situ stage (Stage 0, e.g., without deformation or fracture). The presence of local inflammatory signs in the acute phase and, in particular the edema of the foot, is a strong indicator for diagnosis. In accordance with the literature, we found that foot pain was present in over half of the patients (50.9%) [START_REF] Milne | Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy: a systematic review[END_REF][START_REF] Vopat | Initial diagnosis and management for acute charcot neuroarthropathy[END_REF][START_REF] Kucera | Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience[END_REF]. Due to the very good prognosis of the in situ stage, diagnosis of acute CN must be made as early as possible, i.e. as soon as local inflammatory signs appear in a patient with diabetes with peripheral neuropathy. A triggering factor was also noted in 41.7% of our patients, most often corresponding to a foot trauma. Other studies [START_REF] Game | Audit of acute Charcot's disease in the UK: the CDUK study[END_REF] have reported cases following surgery, whereas only four cases were noted in our work

To confirm the diagnosis of acute CN, MRI of foot was performed in two-thirds of cases. However, the classification proposed by Chantelau in 2014 to describe the osteoarticular involvement was largely unknown and difficult to interpret. Many patients had missing data (n = 302) in the description of the lesions [START_REF] Chantelau | Is the Eichenholtz classification still valid for the diabetic Charcot foot?[END_REF][START_REF] Chantelau | Evaluation of the diabetic charcot foot by MR imaging or plain radiography-an observational study[END_REF]. Radiography, less sensitive than MRI, was only performed in half of patients in the acute phase, yet standard foot X-rays and MRI are essential elements of the initial assessment. X-rays are used to rule out a fracture, and radiographs will be normal in the very early phase of CN. MRI is used to confirm the early diagnosis by showing intra-osseous edema. At this stage, unloading is essential to avoid fractures and changes in the foot architecture. In addition, in the context of diabetes, complications should be assessed regularly (ophthalmological, nephrological, cardiological, vascular assessment) to detect asymptomatic anomalies, but this can prove challenging in some cases.

The modalities of foot offloading in acute CN varied between the centers. The removable boot (standard or custom-made, going up to the knee or ankle, or a bivalved cast) was most frequently prescribed. The frequency of prescription of an irremovable device (20.4%), which is the reference, was similar to that of other European countries (between 20 and 35%) [START_REF] O'loughlin | Diabetic charcot neuroarthropathy: prevalence, demographics and outcome in a regional referral centre[END_REF][START_REF] Game | Audit of acute Charcot's disease in the UK: the CDUK study[END_REF][START_REF] Jansen | Clinical management of acute diabetic Charcot foot in Denmark[END_REF] but lower than American practices (about 50%) [START_REF] Schade | A literature-based guide to the conservative and surgical management of the acute Charcot foot and ankle[END_REF]. This could be explained by the need for expert opinion, with close monitoring. It could also arise from the removal of the boot due to wounds, or readjustment of the boot in accordance with edema levels, or preventive anticoagulant treatment. Of note, almost 10% of patients in the acute phase were not given a solution to immobilize their foot. This highlights the need for rigorous information and communication to guide appropriate offloading of acute CN.

In the chronic phase, adaptation of footwear was pre-scribed in 81.5% of cases, with a clear predominance of custom-made orthopedic footwear, performed by a pedorthist. Orthopedic shoeing is standard in the chronic phase of CN, to limit the occurrence of ulceration in case of deformities and to protect the contralateral foot. However, the modalities of this shoeing are not clearly established and should be further studied.

Our study also confirmed that CN is at high risk of foot ulceration, since 84% of our patients had a history of foot wounds and 42% had a wound at inclusion, including a third with a suspicion of soft tissue or bony infection. 21% of our patients had bilateral CN, which is consistent with data from the literature [START_REF] Waibel | Midterm Fate of the Contralateral Foot in Charcot Arthropathy[END_REF]. These patients with bilateral CN showed a higher prevalence of podiatric history (ulceration or amputation) than in patients with unilateral involvement (94.0% vs 81.1%; p = 0.0019). No significant difference was observed in other clinical characteristics between the two groups. Bilateral involvement rarely occurred immediately, but the high number of bilateral forms in our study must encourage a close care of patients with CN to avoid bilateral progression.

Finally, CN surgery was often discussed, but rarely practiced, requiring very specialized surgical teams. It should be noted that nine patients (8.7% of acute CN) were operated in the acute phase. While not recommended, this surgery was performed during the acute phase to treat infections (osteitis, osteomyelitis or osteoarthritis) in two-thirds of cases. The remaining surgeries were used to correct severe morphostatic disorders, with often complex interventions, which is normaly reserved, and increasingly considered, in the chronic phase. The aim is to improve footwear and limit the risk of ulceration to improve the quality of life of patients. There is no consensus on the indications or type of surgery, which can be internal and/or external osteosynthesis. Similarly, the long-term efficacy on the reduction or prevention of these wounds remains to be evaluated. Several studies seek to clarify its value on functional prognosis and quality of life [START_REF] Lahoti | Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7-14-year Follow-up[END_REF].

This study had several limitations. We used a question-naire without follow-up, and some information regarding diabetes complications such as the presence of nephropathy were only available as declarative information. In addition, some data were missing due to the different management between centers. Imaging data were often incomplete, high-lighting the frequent ignorance of radiological classifications, and an absence of clear description and interpretation of MRIs. Furthermore, it demonstrates the lack of consensus regarding the imaging technique to be used in the diagnosis of Charcot foot, which may have contributed to the heterogeneity observed in the study. Standard radiography is the first-line examination because it is accessible and inexpensive, but it does not allow for an early diagnosis. MRI is currently the most sensitive examination to confirm the diagnosis of acute Charcot foot, but its interpretation remains delicate and requires a radiologist experienced in this pathology. Finally, no follow-up was carried out, making it impossible to establish the future of patients. However, the main aim of this work was to describe the population of CN followed in France and Belgium and to describe the disparities in management in order to propose future recommendations. The diabetic foot working group has two on-going projects focusing either on acute or chronic CN (CharQUAM study), and 30 (98%) of centers were willing to supply information to a diabetic foot registry.

Conclusion

This study confirms the frequent diagnostic delay, the lack of consensus on the imaging necessary for the diagnosis, the often removable offloading modes and the transition to the chronic form secondary to non-adapted management. In the acute phase, foot offloading associated with a good observance is essential until inflammation reduces. This management must be followed by provision of suitable footwear in the chronic phase. This study carried out by the diabetic foot working group of the Francophone Society of Diabetes provides an initial inventory of this rare but serious com-plication of diabetes mellitus. A medium-and long-term evaluation of practices, particularly in terms of benefits on morbidity and mortality, and clear international guidelines is necessary to improve the prognosis of CN, and this should soon be addressed by the upcoming international working group on diabetic foot recommendations.

Acknowledgements

We thank Sarah Kabani for editing the article, Pascale Fabbro-Perray for methodological help, Jean Philippe Lavigne for critical reading of the manuscript and Anne-Clarisse Simonet for reglementary assistance. EPiChar study group: Florence Baudoux (CHRU Lille), Marie Martine Bonello Faraill (CHU Nice), Pierre Bonnin (CH Annecy-Genevois), Florence Bouilloud (Hôpital Foch, Suresnes), Miguel Bourgade (CH La Trinité), Marie Cazaubiel (CH Bron, Tourcoing), Vaneva Chinganmartino (CHU Pointe-à-Pitre), Sylvaine Clavel (CH Le Creusot), Enrique Da Costa Correia (CH Vichy), Fabrice Devemy (CH Lens), Maud François (CHU Reims), Sylvie Grandperret-Vauthier (CHU Besançon), Laurence Kessler (CHU Strasbourg), Amal Lemoine (CH Vienne), Jacques Martini (CHU Rangueil, Toulouse), Arnaud Monier (CH Chartres), Myriam Moret (HCL Louis Pradel, Bron), Marie Muller (CHU Michallon, Grenoble), Vincent Rigalleau (CHU Haut-Lévêque, Pessac), Geneviève Crouzeix (CHU Brest), Nathalie Vigier Simorre (CH Narbonne), Julien Vouillarmet (HCL Lyon Sud, Pierre Bénite). Author contributions S.S., GHV and CAJ conceived the study. S.S. wrote the manuscript. ZZ and CS conducted the statistical analysis. S.S. and CAJ interpreted the data. AS, GHV, JPL reviewed the manuscript. CAJ provided the medical data of the patients. S.S. is the guarantor of this works and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not for-profit sectors.

Data availability

The datasets generated and analysed during the cur-rent study are available from the corresponding author on reasonable request.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest. Ethical approval Our work was performed according to the guidelines of good clinical practice and the Declaration of Helsinki. The study was approved by the ethical committee (CPP Est-III, #2018-A01721-54) and registered on clinicaltrials.gov (#NCT03744039). Consent to participate Written informed consent was obtained from all patients before participation.


Stavropoulos Evangelos
email: evangelos.stavropoulosvasilakis@cea.fr

Pierre Vasilakis

Alain Kestener

Alain Cartalade

Genty

Multi-Architecture

Multi-architecture adaptive Mesh Refinement Lattice-Boltzmann method for multi-phase and porous media flows

Multi-architecture Adaptive Mesh Refinement Lattice-Boltzmann Method for multi-phase and porous media flows E. STAVROPOULOS VASILAKIS July 2022

The work presented herein proposes an implementation of an Adaptive Mesh Refinement (AMR) algorithm for Lattice Boltzmann Methods, focusing on code portability and optimisation on different architectures. The Kokkos [START_REF] Edwards | Kokkos: Enabling manycore performance portability through polymorphic memory access patterns[END_REF] C++ scientific computing library is used, to exploit various available high performance computing (HPC) resources, CPUs or GPUs, shared or distributed memory systems alike, and stay up-to-date with their technological advancements.

The proposed method employs a single time-step, the BGK collision operator and a Lax-Wendroff [2] spatial scheme, to accommodate computational cells of different sizes. The domain is discretised by a cell-centred mesh, organised in a block-based octree structure; computations, refinement or coarsening are performed per-block. Block communication uses ghost cells' layers, filled by quadratic polynomial interpolations. The refinement accounts for normalised gradients and coarsening occurs automatically when refinement is not required on neighbouring blocks. Preliminary assessment and validation, indicate that computations and hard disk I/O operations get accelerated up to 5 times, compared to a fully refined uniform mesh, without loss of accuracy.

The method shows a great potential for application on complex physical problems of industrial interest.


Plant Economy at Early Bronze Age Tel Yarmouth (Israel)

Aurélie Salavert *

Environmental context

The vegetation is characterized by a maquis whit Pistacia lentiscus and Quercus calliprini as dominant species.

Tell Yarmouth is situated between 360 and 400 m a. s. l. at the foot of the central mountain chain, 25 km south-west of Jerusalem.

The landscape around Tel Yarmouth.

On the left, Pistacia lentiscus ; on the right, Quercus calliprinos.

Archaeological context

Topographical map of the tell (in De Miroschedji 1999a)

The site is a 16 ha settlement composed by an Acropole and a Lower City (de Miroschedji 1999a).

A total of 1081 l of sediment has been wet-sieved in 2004 from the area B (palatial context) and J (domestic context). Area B is composed of 2 superimposed palaces with ashy layers (palace B1-EB IIIC is situated on top of palace B2). The area J, dated to the EB IIIB (J-2) period, was destroyed by fire. The area C (domestic context) was sampled for botanical remains during the late 1980s, however without recording of neither sampling methods nor sample volumes. Samples have been sieved by manual flotation with 1 to 4 mm mesh. Charred macroremains were sorted out from 3 l of sieve refuse with the help of a binocular microscop.

Air view of the site (in [START_REF] De | Rapport Tel Yarmouth. Rapport préliminaire de la 13ème campagne[END_REF] Tel Yarmouth (Khirbet Yarmuk) is excavated by P. de Miroschedji (CNRS, CRFJ) since 1980. It's an important site of the southern Levant, that has been occupied from the EB I (3500 BC) to the Byzantin period. During the EB II and EB III (3000-2500 BC), the site appears as a City-state with a flourishing palatial economy. The site was abandonned in the EB IIIC period (2300 BC).

The paleoethnobotanical study of Tel Yarmouth has been carried out in 2004-2005 in the framework of a Master's thesis [START_REF] Salavert | Paléoenvironnement et économie végétale du site de Tel Yarmouth (âge du Bronze, Israël). Approches anthracologique et carpologique[END_REF]. It mainly aims to comprehend the vegetal The paleoethnobotanical study of Tel Yarmouth has been carried out in 2004-2005 in the framework of a Master's thesis [START_REF] Salavert | Paléoenvironnement et économie végétale du site de Tel Yarmouth (âge du Bronze, Israël). Approches anthracologique et carpologique[END_REF]. It mainly aims to comprehend the vegetal economy of the site and to enhance the importance of the fruit cultivation around the tell during the EBII and EB III periods. economy of the site and to enhance the importance of the fruit cultivation around the tell during the EBII and EB III periods.

Material and methods

�

Results

A little more than 3 700 macrorests and 33 taxa have been identified from areas B, C and J.

Cereals -Emmer (Triticum dicoccum) and barley (Hordeum vulgare) are identified in all three areas (67% of the total remains in area B, 26% in area C and 36% in area J). Glumes and spikelet forks from wheat represent the major part of the cereal assemblage (81% in area B, 58% in area C and 72% in area J). Pulses -Pulses are rare on the site, lentil (Lens culinaris) being the main species identified.

Weed and wlld plants -A total of 17 taxa have been identified, representing 10% in area B and 8% in areas C and J respectively. Lolium sp. is the most frequentely identified taxon, followed by, among others, Hordeum spontaneum, Galium, Scorpiurus and Thymeleae.

Fruit species -Pistacia sp., Ficus cf carica, Vitis vinifera and Olea europaea are present, with olive being the most important species. Remains of olive, in the form of crushed stones, represent 84% of fruit remains in area B, 35% in area C and 89% in area J.

Discussion

The vegetal economy of Tel Yarmouth is based on the cultivation on winter crops : emmer, hulled barley and lentils. Weeds (Lolium, Phalaris, Avena...) indicate the same seasonality [START_REF] Charles | Introductory remarks on the cereals[END_REF]. Triticum dicoccum, Hordeum vulgare and Lens culinaris are the three main crops in Palestine during the Early Bronze age [START_REF] Haelbaek | Appendix A. Plant economy in ancient Lachish[END_REF][START_REF] Hopf | Plant remains, Strata IV-I[END_REF][START_REF] Hopf | Appendix B. Jericho plant remains[END_REF]. Olive remains represent 23% of the total assemblage. Crushed endocarps are interpreted as press remains (jift). They are characteristic of olive oil production and probably indicate the presence of an oil-fabric on the settlement or in its vicinity. Indeed, area H in the north of the Lower City seems to be linked to the production of olive oil (de Miroschedji 1999a). Today, jift is used as fuel in many oil-producing countries [START_REF] Brun | Le vin et l'huile de la Méditerranée antique[END_REF]. This was probably the case at Yarmouth too. Furthemore, the percentages of olive endocarps reamin more or less constant throughout the period. It indicates a stability in the production of olive oil during the EB II and EB III. The olive tree culture, which provides a long-term return, requires an economic, social and politic stability [START_REF] Finkelstein | Settlement, demographic, and economic patterns in the highlands of Palestine in the Chalcolithic and Early Bronze Periods and the beginnig of urbanism[END_REF].

The importance of olive tree at Tell Yarmouth is also noticeable through the anthracological study where olive wood is represented by 63% of the identified fragments [START_REF] Salavert | Paléoenvironnement et économie végétale du site de Tel Yarmouth (âge du Bronze, Israël). Approches anthracologique et carpologique[END_REF]. The choice of the installation of the settlement seems to have been motivated, at least in part, by the potential for agricultural production and especially that of olive cultivation [START_REF] Rosen | The social response to environmental change in early Bronze Age Canaan[END_REF]. The culture and the production of olive oil might have played a role in the developed and stable economy of Tell Yarmouth. Further palaeoethnobotanical investigations should give informations about the trade and the complementarity between contemporary settlements. This should provide a general view of vegetal economy during the Early Bronze age in Palestine.

  Pistacia sp. TY-J L. 2819 Vitis vinifera TYC L.603 Olea europaea TYJ .2819 Galium sp.TY-J L. 2821 Hordeum spontaneum TY-J L. 2819


Jean-Francois Korobelnik
email: jean-francois.korobelnik@chu-bordeaux.fr

Varun Chaudhary

Se Paul Mitchell

Woong Kang

Ramin Tadayoni

Helmut Allmeier

Jinkyung Lee

Xin Zhang

Tobias Machewitz

Clare Bailey

Jean-Franc ¸ois

Korobelnik Varun

Chaudhary Paul

Mitchell Se

Tadayoni Ramin

Allmeier Helmut

Lee Jinkyung

Zhang Xin

Machewitz Clare Tobias

Bailey

J.-F Korobelnik

J.-F Korobelnik

S W Kang

Á X Zhang

Á T Machewitz

XTEND: Two-Year Results from a Global Observational Study Investigating Proactive Dosing of Intravitreal Aflibercept in Neovascular Age-Related Macular Degeneration

ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Mean (95% CI) CST was -106 (-114, -99) lm and -109 (-117, -102) lm at M12 and M24, respectively. At M24, 41.5% of patients had a BCVA C 70 letters. Patients received a mean ± SD of 7.7 ± 2.7 injections by M12 and 10.8 ± 5.0 injections by M24 (3.1 injections between M12 and M24). Adverse events were consistent with the known safety profile of IVT-AFL. Conclusion: The 24-month results indicate that, in routine clinical practice, a proactive IVT-AFL regimen achieves functional improvements in patients with treatment-naı ¨ve nAMD. The proportion of patients achieving C 70 letters at M24 increased, and patients with baseline BCVA C 70 letters maintained vision regardless of the followed IVT-AFL label. Patients with neovascular age-related macular degeneration (nAMD) tend to achieve lower visual acuity gains in routine clinical practice than in randomized clinical trials.

The XTEND study is the first study to gather global real-world evidence on proactive intravitreal aflibercept (IVT-AFL) treatment regimens in patients with treatment-naı ¨ve nAMD in routine clinical practice and during the COVID-19 pandemic.

What was learned from the study?

Proactive IVT-AFL treatment resulted in meaningful functional and anatomic improvements that were generally maintained across the 24-month analysis period.

The proportion of patients achieving C 70 letters at month 24 increased, and patients with baseline best-corrected visual acuity C 70 letters maintained vision regardless of the followed IVT-AFL label.

INTRODUCTION

Anti-vascular endothelial growth factor (VEGF) therapies, such as intravitreal aflibercept (IVT-AFL), ranibizumab, and brolucizumab, have demonstrated robust visual improvements in patients with neovascular age-related macular degeneration (nAMD) [1][START_REF] Schmidt-Erfurth | Intravitreal aflibercept injection for neovascular age-related macular degeneration: ninety-six-week results of the VIEW studies[END_REF][START_REF] Silva | Treat-and-extend versus monthly regimen in neovascular age-related macular degeneration: results with ranibizumab from the TREND study[END_REF][START_REF] Ohji | Efficacy and treatment burden of intravitreal aflibercept versus intravitreal ranibizumab treat-and-extend regimens at 2 years: network meta-analysis incorporating individual patient data meta-regression and matching-adjusted indirect comparison[END_REF][START_REF] Dugel | HAWK and HARRIER: ninety-six-week outcomes from the phase 3 trials of brolucizumab for neovascular agerelated macular degeneration[END_REF][START_REF] Mitchell | Efficacy and safety of intravitreal aflibercept using a treat-andextend regimen for neovascular age-related macular degeneration: the ARIES study[END_REF]. However, the outcomes observed in randomized controlled trials (RCTs) are not always realized in routine clinical practice; patients in routine practice tend to receive fewer anti-VEGF injections, particularly after the first year of treatment, and achieve lower visual acuity (VA) gains than typically observed in RCTs [START_REF] Lee | Difference in treatment burden of neovascular age-related macular degeneration among different types of neovascularization[END_REF][START_REF] Okada | Defining nonadherence and nonpersistence to anti-vascular endothelial growth factor therapies in neovascular age-related macular degeneration[END_REF][START_REF] Nguyen | Neovascular age-related macular degeneration: a review of findings from the real-world fight retinal blindness! Registry[END_REF][START_REF] Holz | Multi-country real-life experience of anti-vascular endothelial growth factor therapy for wet age-related macular degeneration[END_REF].

While RCTs provide a more controlled environment with selective inclusion criteria, observational studies allow for greater insight into effectiveness and treatment patterns in more heterogeneous populations and elucidate the effects that adherence to and persistence with treatment have on visual outcomes [START_REF] Daien | Evolution of treatment paradigms in neovascular age-related macular degeneration: a review of real-world evidence[END_REF]. Thus, real-world evidence (RWE) is valuable to better understand and address discrepancies in outcomes between RCTs and real-world experience [START_REF] Daien | Real-world data in retinal diseases treated with anti-vascular endothelial growth factor (Anti-VEGF) therapy-a systematic approach to identify and characterize data sources[END_REF][START_REF] Burns | Realworld evidence for regulatory decision-making: guidance from around the world[END_REF][START_REF] Klonoff | The new FDA real-world evidence program to support development of drugs and biologics[END_REF].

To date, the RWE for IVT-AFL in patients with nAMD has been generated in multicenter, single-country settings: PERSEUS in Germany [START_REF] Eter | PERSEUS 24-month analysis: a prospective non-interventional study to assess the effectiveness of intravitreal aflibercept in routine clinical practice in Germany in patients with neovascular age-related macular degeneration[END_REF], PERSEUS-IT in Italy [START_REF] Nicolo | PERSEUS-IT 24-month analysis: a prospective observational study to assess the effectiveness of intravitreal aflibercept in routine clinical practice in Italy in patients with neovascular age-related macular degeneration[END_REF], and RAINBOW in France [START_REF] Weber | Impact of intravitreal aflibercept dosing regimens in treatment-naı ¨ve patients with neovascular age-related macular degeneration: 2-year results of RAINBOW[END_REF][START_REF] Weber | Impact of intravitreal aflibercept dosing regimens in treatment-naı ¨ve patients with neovascular age-related macular degeneration in routine clinical practice in France: results from the RAINBOW study[END_REF][START_REF] Weber | Effectiveness and safety of intravitreal aflibercept in patients with wet age-related macular degeneration treated in routine clinical practices across France: 12-month outcomes of the RAINBOW study[END_REF]. Analyses of patient electronic records in the UK have also provided RWE for IVT-AFL [START_REF] Lee | UK AMD/DR REPORT IX: comparative effectiveness of predominantly as needed (PRN) ranibizumab versus continuous aflibercept in UK clinical practice[END_REF].

XTEND (eXtended and proacTive dosing regimEn in treatment-Naı ¨ve patients with neovascular age-related macular Degeneration) is a multinational, multicenter, observational, prospective study designed to examine the effectiveness of proactive treatment regimens of IVT-AFL following the broadening of the label to include a treat-and-extend (T&E) regimen after the three initial monthly injections in patients with treatment-naı ¨ve nAMD. Two IVT-AFL labels are approved for nAMD: the European Medicines Agency (EMA)-aligned label, whereby three monthly injections are followed by a minimum of 8-week intervals in year 1 [START_REF]Eylea (Aflibercept). Summary of product characteristics[END_REF], and the non-EMA-aligned label, whereby the minimum interval is 4 weeks [START_REF]Highlights of prescribing information[END_REF]. For both labels, the treatment interval may be extended beyond 2 months after year 1 if specific visual and anatomic criteria are met, thereby balancing injection frequency and associated treatment burden with outcomes.

XTEND is a prospective observational study that assesses the long-term effectiveness, treatment patterns, and safety of IVT-AFL treatment in real-world settings. Here, we report the primary endpoint and 24-month outcomes of XTEND in the ongoing, 36-month XTEND study. Data are presented for the overall population and stratified by IVT-AFL label type. As the COVID-19 pandemic began during the study period, there was an opportunity to reflect on how routine clinical practice with IVT-AFL was impacted. The analyses presented here are explorative and descriptive, and there were no pre-defined hypotheses.

To date, XTEND is the largest, long-term, prospective, observational real-world study of IVT-AFL in treatment-naı ¨ve patients with nAMD and aims to generate global insights into opportunities for the optimization of nAMD management in clinical practice. It is the first RWE study to be conducted after the IVT-AFL label was broadened to include a T&E regimen after the three initial monthly injections in patients with nAMD [START_REF]Eylea (Aflibercept). Summary of product characteristics[END_REF][START_REF]Highlights of prescribing information[END_REF].

METHODS

Study Design/Participants

XTEND

(ClinicalTrials.gov identifier: NCT03939767) is an ongoing, multinational, multicenter, observational, prospective study examining the effectiveness of real-world proactive treatment regimens of IVT-AFL in patients with treatment-naı ¨ve nAMD.

The study is conducted in accordance with guidelines and regulations of the EMA and applicable local law(s) and regulation(s). The protocol and any amendments were reviewed and approved locally by each study independent ethics committee or institutional review board before the start of the study. The study enrolled patients between May 2019 and May 2020, and the patient follow-up period is 36 months.

Patients received IVT-AFL (proactive regimen: fixed dosing or T&E) according to the local label, local standard of care, and judgment of the treating physician. For the T&E regimen, treatment intervals can be extended in 2-to 4-weekly increments to a maximum of 12 or 16 weeks according to the national label-either EMA-aligned or non-EMA-aligned.

In year 1, following three initial monthly injections, the minimum treatment interval was 8 weeks in the EMA-aligned label or 4 weeks in the non-EMA-aligned label. The countries following the EMA-aligned label are Argentina, Belgium, mainland China, Colombia, Denmark, France, Ireland, Italy, Norway, South Korea, Spain, Sweden, Thailand, and the UK; countries following the non-EMA-aligned label are Australia, Canada, and Switzerland.

Ethical Approval

No master Independent Ethics Committee (IEC) or Institutional Review Board (IRB) approval was obtained, as no participating study site was deemed to be the main center for the study. Electronic Supplementary Material (ESM) Table S1 lists the local IRB/IEC committee names and approval numbers in all participating countries, where relevant, under local law. The XTEND study was an observational study in which IVT-AFL was prescribed in the customary manner in accordance with the terms of the marketing authorization. There was no assignment of patients to a particular therapeutic strategy. All treatment decisions fell within current practice, and the prescription of IVT-AFL was clearly separated from the decision to include the patient in the study. No additional diagnostic or monitoring evaluations were required for participation in the study. Epidemiological methods were used for the analysis of the collected data.

The XTEND study was conducted in accordance with the Helsinki Declaration of 1964 and the applicable EMA guidelines and local laws and regulations in each country. The recommendations of the European Federation of Pharmaceutical Industries and Associations, European Network of Centers for Pharmacoepidemiology and Pharmacovigilance, Good Pharmacovigilance Practices (GVP module VI), and International Council for Harmonization Guideline E3: Good Clinical Practice were also followed wherever possible. In all countries, where required, the protocol and any amendments were reviewed and approved by each study site's IEC or IRB before and during the study. ESM Table S1 provides the full list of Ethics Approval Boards that approved the study. All patients gave informed consent to participate in the study.

Patients

Male or female patients aged C 50 years with nAMD were eligible for enrollment if they were naı ¨ve to any treatment, including anti-VEGF therapy. If both of a participant's eyes fulfilled the inclusion criteria, only the eye with the worst VA at baseline was included in the study [START_REF]Eylea (Aflibercept). Summary of product characteristics[END_REF][START_REF]Highlights of prescribing information[END_REF]. Exclusion criteria listed in the national Summary of Product Characteristics included contraindications to IVT-AFL, eye diseases that may require surgery during the observation period in the study eye, or retinal disease that may interfere with treatment of nAMD (see ESM Table S2 for full inclusion and exclusion criteria) [START_REF]Eylea (Aflibercept). Summary of product characteristics[END_REF][START_REF]Highlights of prescribing information[END_REF]. The initial visit, first IVT-AFL 2 mg treatment, follow-up visits, and end-of-observation visit took place according to routine clinical practice and physician choice.

Procedures

The primary endpoint was mean change in bestcorrected VA (BCVA) using Early Treatment Diabetic Retinopathy Study (ETDRS) letters from baseline to month 12. The preferred method of measuring BCVA is by ETDRS letters or a Snellen chart with conversion to ETDRS letters. Secondary endpoints included, from baseline: change in BCVA at 24 months; change in BCVA by intended treatment regimen; the proportion of patients with predetermined visual gains and losses (equivalent to 5, 10, and 15 ETDRS letters); the proportion of patients achieving a Snellen equivalent of 20/40 or better; change in central subfield thickness (CST); and injection number. Spectral-domain and time-domain optical coherence tomography were used to measure CST.

The COVID-19 pandemic began after study initiation; therefore, additional COVID-19 sensitivity analyses were performed. The 'pre-COVID-19' group included all patients who received their regular end-of-observation visit before the start date of the COVID-19 pandemic or who received their first injection 180 days prior to their country of residence COVID-19 start date. The pandemic start date (between February and March 2020) was provided by Bayer representatives based on individual national guidelines. The 'during COVID-19' group included all other patients. Differing national guidance in response to the pandemic may have led to changes from the planned proactive treatment regimens.

Safety was assessed throughout the study period. All adverse events (AEs) were summarized using the Medical Dictionary for Regulatory Activities (MedDRA) coding system. AEs were considered to be treatment emergent if they started between the first IVT-AFL injection and 30 days after the last injection. Safety analyses were performed on treatment-emergent AEs (TEAEs); AEs that were not treatment emergent were listed without further analysis.

Statistical Analysis

Statistical analyses were explorative and descriptive, and there were no predefined hypotheses. An overall enrollment target of C 2000 patients (C 1200 and C 250 in the EMAaligned and non-EMA-aligned groups, respectively) was determined by feasibility; this allows for a change from baseline in BCVA letters within a 95% confidence interval (CI) of ± 1.0 letters for the EMA-aligned group and ± 2.2 letters for the non-EMA-aligned group.

All variables were analyzed descriptively with appropriate statistical methods: categorical variables by frequency tables (absolute and relative frequencies) and continuous variables by sample statistics (i.e., mean, standard deviation [SD], minimum, median, quartiles, and maximum). Continuous variables are described by absolute value and as change from baseline per analysis time point, if applicable. All analyses were performed by label regimen (countries reflecting the EMA-aligned and the non-EMAaligned labels). For VA and CST, the last observations were carried forward. Baseline values were not carried forward. Other variables were not imputed. Statistical evaluation was performed by using the software package SAS release 9.4 or higher (SAS Institute Inc., Cary, NC, USA), except when noted otherwise.

Patients who received C 1 IVT-AFL injection were included in the safety analysis set (SAS). Patients were included in the full analysis set (FAS) if they received at least one IVT-AFL injection and had at least one VA measurement with an available BCVA letter score at baseline and at least one post-baseline assessment valid for analysis (i.e., measured C 5 days after an injection). VA and CST outcomes were evaluated at baseline and monthly until month 24.

RESULTS

Patients

At the time of the 24-month analysis, XTEND had enrolled 1561 patients from 127 centers (Fig. 1). A total of 1550 patients were included in the SAS: 1221 (78.8%) patients in the EMAaligned group and 329 (21.2%) patients in the non-EMA-aligned group. There were 1466 patients (93.9%) included in the FAS: 1165 (79.5%) patients in the EMA-aligned group and 301 (20.5%) patients in the non-EMA-aligned group. Eighty-four patients were excluded from the FAS due to no VA assessment at baseline and/or post baseline.

For the overall population, the mean ± SD age was 78.7 ± 8.5 (range 50-100) years, and 891 patients (60.8%) were female (Table 1). At baseline, the mean ± SD BCVA was 54.3 ± 20.3 letters and the mean ± SD CST was 374 ± 126 lm. Baseline characteristics were similar in both label groups.

Functional Outcomes

For the 1466 patients in the FAS, the mean change in BCVA from baseline (54.3 ± 20.3 letters) was ? 4.3 ± 17.6 letters at month 12 and ? 2.3 ± 19.5 letters at month 24 (Fig. 2a,b; ESM Table S3). In the EMA-aligned group, the mean (95% CI) change in BCVA was ? 4.6 (3.6, 5.6) letters at month 12 and ? 2.3 (1.2, 3.4) letters at month 24. In the non-EMA-aligned group, the mean (95% CI) change in BCVA was ? 3.4 (1.5, 5.2) letters at month 12 and ? 2.2 (0.1, 4.3) letters at month 24.

The mean BCVA changes at months 12 and 24 were numerically highest in patients with a baseline BCVA of \ 35 letters (? 15.1 ± 23.3 letters at month 12 and ? 12.3 ± 23.5 letters at month 24). In patients with a baseline BCVA of 35-69 letters, there were improvements of ? 4.5 ± 17.6 letters at month 12 and ? 2.7 ± 19.6 letters at month 24. In patients with a baseline BCVA of C 70 letters, BCVA was maintained at C 70 letters (month 12, -0.7 ± 11.6 letters; month 24, -3.0 ± 14.9 letters) (Fig. 2c).

Of the 1466 patients in the FAS with a BCVA assessment at month 24, 1263 patients (86.2%) maintained vision (i.e., lost B 15 letters). Between baseline and month 24, 731 patients (49.9%) gained C 5 letters; 497 patients (33.9%) gained C 10 letters; 332 patients (22.6%) gained C 15 letters; and 203 patients (13.8%) lost C 15 letters (Fig. 2d). In addition, the proportion of patients with a BCVA C 70 letters was 28.1% (412/1466) at baseline and increased to 41.5% (609/1466) at month 24 (ESM Table S4). There were no marked differences between the letter gains and losses by months 12 and 24, nor between the two label groups (Fig. 2d).

When stratified by intended treatment regimen (T&E or fixed dosing), patients receiving the T&E regimen had a mean ± SD BCVA gain of ? 2.6 ± 19.4 letters at month 24, and patients on the fixed dosing regimen had a mean ± SD BCVA gain of 0.0 ± 19.8 letters at month 24.

Anatomic Outcomes

In the overall FAS, mean (95% CI) change in CST from baseline (374 ± 126 lm) was -106 (-114, -99) lm at month 12 and -109 (-117, -102) lm at month 24. Changes at month 24 were numerically similar in both label groups. In the EMA-aligned group, a decrease in CST was achieved by month 12 (mean [95% CI]; -107 [-116, -98] lm) and maintained through to month 24 (-109 [-118, -100] lm); in the non-EMA-aligned group, a similar numerical decrease in CST was achieved by month 12 (-103 [-118, -86] lm) and maintained through to month 24 (-109 [-123, -96] lm; ESM Table S5).

Treatment Patterns and Exposure

For the overall population, the mean ± SD time in study (defined as the mean time between first and last IVT-AFL injections) was 20.0 ± 5.9 months. Patients in the FAS received a mean ± SD of 5.3 ± 1.5 injections by month 6; 7.7 ± 2.7 injections by month 12; and 2). In both label groups, the majority of IVT-AFL injections were received by month 12, with a mean increase of 3.1 injections from months 12 to 24. In the EMA-aligned group, patients received a mean ± SD of 7.4 ± 2.6 and 10.5 ± 4.9 injections by months 12 and 24, respectively. In the non-EMA-aligned group, patients received a mean ± SD of 8.6 ± 2.8 and Classified by the investigator using fixed categories, considering information in medical records or provided directly by the patient 12.0 ± 5.2 injections by months 12 24, respectively.

In the overall FAS, the last completed treatment interval was C 12 weeks in 35.6% (522/ 1466) of patients at month 12 and 37.7% (553/ 1466) of patients at month 24 (Fig. 3). In the EMA-aligned group, the last completed interval was C 12 weeks in 26.8% (312/1165) of patients at month 12 and 38.0% (442/1165) of patients at month 24. In the non-EMA-aligned group, the last completed interval was C 12 weeks in 20.3% (61/301) of patients at month 12 and 36.5% (110/301) of patients at month 24.

Impact of the COVID-19 Pandemic

For the overall FAS, 1195 and 271 patients were stratified into the 'pre-COVID-19' and 'during COVID-19' groups, respectively; mean baseline BCVA was similar in both groups: 55.3 ± 16.6

Safety

Treatment-emergent AEs were reported in 464 (29.9%) patients of the SAS (ESM Table S6). A total of 325 patients (21.0%) reported ocular TEAEs in either eye, and 233 patients (15.0%) reported any ocular TEAE in the study eye. The most common ocular TEAEs (defined as occurring in C 1% of study eyes) were cataract (43/ 1550; 2.8%) and blepharitis (19/1550; 1.2%).

In the total population, considering both eyes, 17 cases of intraocular inflammation were reported. Intraocular inflammation was defined by the following preferred terms: eye infection (n = 6), endophthalmitis (n = 3), anterior chamber cell (n = 2), anterior chamber flare (n = 1), anterior chamber inflammation (n = 1), bacterial endophthalmitis (BE; n = 1), iridocyclitis (n = 1), iritis (n = 1), and uveitis (n = 1). All three patients who reported endophthalmitis received IVT-AFL from a vial and were treated with antibiotics. No cases of retinal vasculitis, retinal occlusive vasculitis, or retinal artery occlusion were reported. Fig. 3 Last completed injection interval up to month 24 (FAS, OC). Data are mean ± SD. EMA European Medicines Agency, FAS full analysis set, OC observed cases, SD standard deviation DISCUSSION XTEND is the largest ongoing global study to date assess proactive IVT-AFL treatment regimens in routine clinical practice in nAMD. Patients with treatment-naı ¨ve nAMD receiving IVT-AFL achieved functional and anatomic improvements by month 12 that were maintained at month 24. The mean improvement in BCVA was ? 4.3 letters and ? 2.3 letters at months 12 and 24, respectively, which is lower than in the VIEW RCT at week 96 (? 7.6 ETDRS letters [START_REF] Schmidt-Erfurth | Intravitreal aflibercept injection for neovascular age-related macular degeneration: ninety-six-week results of the VIEW studies[END_REF]). The proportion of patients with BCVA C 70 letters increased from 28.1% at baseline to 41.5% at month 24. This increase is likely due to patients with baseline BCVA \ 70 letters having the greatest capacity to improve and IVT-AFL preventing deterioration in patients with BCVA C 70 letters.

Patients also had improvements in CST, although these were not as marked as those reported in key RCTs (-106 lm and -109 lm at months 12 and 24, respectively, in XTEND versus -128 lm at week 96 in VIEW [START_REF] Schmidt-Erfurth | Intravitreal aflibercept injection for neovascular age-related macular degeneration: ninety-six-week results of the VIEW studies[END_REF]). Even with the relatively low treatment frequency in XTEND compared with VIEW, treatment with IVT-AFL led to improvements by inhibiting fluid accumulation and leakage.

At months 12 and 24 in XTEND, a mean (± SD) 7.7 ± 2.7 and 10.8 ± 5.0 injections, respectively, had been administered, and an average of 3.1 injections were administered from month 12 to 24. The number of injections observed in XTEND was lower than observed in the VIEW RCTs at week 96 (11.2 injections [START_REF] Schmidt-Erfurth | Intravitreal aflibercept injection for neovascular age-related macular degeneration: ninety-six-week results of the VIEW studies[END_REF]); however, the lower observed injection numbers in the second year of XTEND are consistent with other observational studies of IVT-AFL in nAMD [START_REF] Eter | PERSEUS 24-month analysis: a prospective non-interventional study to assess the effectiveness of intravitreal aflibercept in routine clinical practice in Germany in patients with neovascular age-related macular degeneration[END_REF][START_REF] Nicolo | PERSEUS-IT 24-month analysis: a prospective observational study to assess the effectiveness of intravitreal aflibercept in routine clinical practice in Italy in patients with neovascular age-related macular degeneration[END_REF][START_REF] Cohen | Final 4-year results of the RAINBOW real-world study: intravitreal aflibercept dosing regimens in france in treatment-naive patients with neovascular age-related macular degeneration[END_REF]. The results of this analysis indicate that greater visual and anatomic improvements may have been achieved if treatment regimens were more closely aligned to the labels. Data were not stratified according to gender in the XTEND study; IVT-AFL has been commercially available for[11 years, and, from development until present, there have been no gender-specific effects recorded for IVT-AFL.

XTEND also provides insights into the impact of routine clinical practice on different labels followed globally. The proportion of patients with a last completed interval of C 12 weeks was similar for both groups by 24 months (38.0% for the EMA-aligned label group and 36.5% for the non-EMA-aligned label group), although the injection number was slightly higher in the non-EMA-aligned group at 24 months (12.0 vs. 10.5 in the EMA-aligned group). While similar treatment patterns were observed, the results must be interpreted with caution due to variations from the labels (e.g., shorter treatment intervals), variations from the intended treatment regimen (fixed or T&E), and the variable impact that the COVID-19 pandemic had on healthcare systems.

The safety profile of IVT-AFL over 24 months was consistent with that reported in prior observational studies [START_REF] Eter | PERSEUS 24-month analysis: a prospective non-interventional study to assess the effectiveness of intravitreal aflibercept in routine clinical practice in Germany in patients with neovascular age-related macular degeneration[END_REF][START_REF] Weber | Impact of intravitreal aflibercept dosing regimens in treatment-naı ¨ve patients with neovascular age-related macular degeneration: 2-year results of RAINBOW[END_REF][START_REF] Weber | Impact of intravitreal aflibercept dosing regimens in treatment-naı ¨ve patients with neovascular age-related macular degeneration in routine clinical practice in France: results from the RAINBOW study[END_REF][START_REF] Weber | Effectiveness and safety of intravitreal aflibercept in patients with wet age-related macular degeneration treated in routine clinical practices across France: 12-month outcomes of the RAINBOW study[END_REF][START_REF] Framme | Aflibercept for patients with neovascular age-related macular degeneration in routine clinical practice in Germany: twelve month outcomes of PERSEUS[END_REF]. Three cases of endophthalmitis and one case of BE were observed. BE is a sight-threatening bacterial infection of the interior structures of the eye and is treated through intravitreal or systemic antibiotic injection [START_REF] Callegan | Bacterial endophthalmitis: epidemiology, therapeutics and bacterium-host interactions[END_REF]. Overall, 15,875 injections were observed over 24 months, equating to endophthalmitis affecting one eye per 5292 injections and BE affecting one eye per 15,875 injections.

The strengths of XTEND include the prospective design, long-term study duration, and the large heterogenous population enrolled from 127 centers across 17 countries, with a mean age of patients (78.7 years) that is reflective of patients with nAMD seen in routine clinical practice.

RWE has demonstrated an efficacy gap between outcomes in RCTs and those in routine clinical practice [START_REF] Daien | Real-world data in retinal diseases treated with anti-vascular endothelial growth factor (Anti-VEGF) therapy-a systematic approach to identify and characterize data sources[END_REF][START_REF] Burns | Realworld evidence for regulatory decision-making: guidance from around the world[END_REF][START_REF] Klonoff | The new FDA real-world evidence program to support development of drugs and biologics[END_REF]. RWE provides valuable understanding on treatment exposure, disease progression, disease burden, and long-term safety [START_REF] Daien | Real-world data in retinal diseases treated with anti-vascular endothelial growth factor (Anti-VEGF) therapy-a systematic approach to identify and characterize data sources[END_REF][START_REF] Burns | Realworld evidence for regulatory decision-making: guidance from around the world[END_REF][START_REF] Klonoff | The new FDA real-world evidence program to support development of drugs and biologics[END_REF] and is, therefore, more reflective than RCT data of the outcomes patients can expect in routine clinical practice. Regulatory bodies are increasingly using RWE in conjunction with RCT data to inform decision-making [START_REF] Klonoff | The new FDA real-world evidence program to support development of drugs and biologics[END_REF]. Further, XTEND was conducted before and during the COVID-19 pandemic, providing unique settings from which to generate data from routine clinical practice.

Other large RWE studies of anti-VEGFs have assessed visual and injection number for nAMD in routine clinical practice (e.g. [START_REF] Holz | Ranibizumab treatment in treatment-naive neovascular age-related macular degeneration: results from LUMI-NOUS, a global real-world study[END_REF]). While not necessarily employing the T&E regimen as in the XTEND study, these studies nonetheless concur that there is scope for better vison gains if the approved label for anti-VEGFs is more closely followed [START_REF] Holz | Ranibizumab treatment in treatment-naive neovascular age-related macular degeneration: results from LUMI-NOUS, a global real-world study[END_REF].

Conversely, RWE studies present with limitations inherent in their design. Treatment regimens are standardized based on RCT results [START_REF] Schmidt-Erfurth | Intravitreal aflibercept injection for neovascular age-related macular degeneration: ninety-six-week results of the VIEW studies[END_REF]; however, these standards are not always applied in clinical practice, and high treatment discontinuation rates and variability in assessment modalities can limit the interpretations made from observational studies [START_REF] Okada | Nonadherence or nonpersistence to intravitreal injection therapy for neovascular age-related macular degeneration: a mixed-methods systematic review[END_REF]. Therefore, the limitations of the XTEND study include the high variability of treatment and monitoring schedules in routine clinical practice according to local guidelines, as these are at the attending physician's discretion. Not all patients attend each of the visits, and not all assessments are conducted each visit, which leads to missing data that may limit the study's interpretations. In addition, the XTEND study took place during the COVID-19 pandemic, and, as per national guidelines or recommendations in some countries, not all patients could be treated as initially intended at the start of the study. Therefore, many patients did not have the opportunity to be extended as rapidly as may have occurred without the pandemic.

CONCLUSION

In the 24-month analysis of XTEND, proactive IVT-AFL treatment resulted in meaningful improvements in BCVA and CST and extended treatment intervals in patients with treatmentnaı ¨ve nAMD following either the EMA-aligned label or the non-EMA-aligned label. Visual improvements were achieved within the first 12 months and were generally maintained across 24 months during the pandemic.

European Union as necessary for conducting legitimate research. This applies to on new medicines and indications that have been approved by the EU and US regulatory agencies on or after 1 January 2014. Interested researchers can use www.clinicalstudydatarequest.com to request access to anonymized patient-level data and supporting documents from clinical studies to conduct further research that can help advance medical science or improve patient care. Information on the Bayer criteria for listing studies and other relevant information is provided in the 'Study sponsors' section of the portal. Data access will be granted to anonymized patient-level data, protocols, and clinical study reports after approval by an independent scientific review panel. Bayer is not involved in the decisions made by the independent review panel. Bayer will take all necessary measures to ensure that patient privacy is safeguarded.

Declarations

Conflict of Interest. Jean-Franc ¸ois Korobelnik has received consulting fees from Abb-Vie, Apellis, Bayer, Janssen, Nano Retina, Roche, The ´a Pharmaceuticals, and Carl Zeiss Meditec AG; and is a member of data safety monitoring boards or advisory boards for Alexion, Novo Nordisk, and Oxular. Varun Chaudhary has received grants from Allergan Inc., Bayer Healthcare, Novartis, and Roche; consulting fees from Allergan-AbbVie, Apellis, Bayer, Care Zeiss Meditec AG, Janssen, Nano Retina, Roche, and The ´a Pharmaceuticals; and is a scientific advisor for Alcon Laboratories, Bayer Healthcare, Novartis, and Roche. Paul Mitchell has received consulting fees from Allergan, Apellis, Bayer, Novartis, and Roche; lecture honoraria from Bayer; support for attending meetings and/or travel from Bayer and Roche; and is a member of data safety monitoring boards or advisory boards for Apellis and Bayer. Se Woong Kang has received personal fees and non-financial support from Bayer Korea. Ramin Tadayoni has received consulting fees from Alcon Laboratories, Allergan, Bausch ? Lomb, Novartis, Roche, Genentech, and ZEISS; and is a board member for Alcon Laboratories, Alimera Sciences, Allergan, Bausch ? Lomb, Bayer, FCI, and Novartis. Helmut Allmeier and Xin Zhang are employees of Bayer Consumer Care AG. Tobias Machewitz and JinKyung Lee are employees of Bayer AG. Clare Bailey has received honoraria from Alimera Sciences, Apellis, Bayer, Boehringer Ingelheim, Janssen, Novartis, and Roche; and is a member of advisory boards for Alimera Sciences, Apellis, Bayer, Boehringer Ingelheim, Janssen, Novartis, and Roche.

Ethical Approval. The XTEND study was conducted in accordance with the Helsinki Declaration of 1964 and the applicable EMA guidelines and local laws and regulations in each country. The recommendations of the European Federation of Pharmaceutical Industries and Associations, European Network of Centers for Pharmacoepidemiology and Pharmacovigilance, Good Pharmacovigilance Practices (GVP module VI), and International Council for Harmonization Guideline E3: Good Clinical Practice were also followed wherever possible. In all countries, where required, the protocol and any amendments were reviewed and approved by each study site's IEC or IRB before and during the study. The full list of Ethics Approval Boards that approved the study is provided in ESM Table 1. All patients gave informed consent to participate in the study.

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Fig. 1

 1 Fig. 1 Patient disposition. a Patients could have had more than one reason for exclusion from enrollment. b Patients with a visit within the 12-month (360 ± 60 days) or 24-month (720 ± 60 days) visit windows. EMA European

Fig. 2

 2 Fig. 2 Visual acuity outcomes in the EMA-aligned label, non-EMA-aligned label, and overall population (FAS, LOCF). a Absolute mean BCVA over 24 months. b Mean change in BCVA over 24 months. c Mean change in BCVA over 24 months stratified by baseline visual acuity. d Proportion of patients stratified by BCVA categorical score change over 24 months. Symbols represent mean

  letters and 54.1 ± 21.1 letters, respectively. The mean (95% BCVA change from baseline at 6 and 12 months was ? 5.6 (4.0, 7.2) and ? 4.3 (2.5, 6.0) letters, respectively, in the 'pre-COVID-19' group, and ? 4.0 (3.0, 4.9) letters and ? 4.4 (3.3, 5.4) letters, respectively, in the 'during COVID-19' group. At month 24, the mean (95% CI) change in VA was numerically higher in patients who started treatment during the COVID-19 pandemic (n = 1195; ? 2.4 [1.3, 3.6] letters) than pre-COVID-19 (n = 271; ? 1.7 [-0.3, 3.6] letters). Mean (± SD) baseline CST was comparable in the 'pre-COVID-19' (364 ± 119 lm) and 'during COVID-19' (375 ± 127 lm) groups. The mean CST changes from baseline were numerically similar for the 'pre-COVID-19' and 'during COVID106 ± 126 lm vs. n = 904; -101 ± 125 lm) and at month 24 (n = 179; -107 ± 123 lm vs. n = 949; -109 ± 132 lm). The mean (± SD) numbers of injections for the 'pre-COVID-19' group at 12 and 24 months (n = 271; 7.6 ± 2.5 and 10.9 ± 4.8, respectively) were similar to the 'during COVID-19' group at both time points (n = 1195; 7.8 ± 2.8 and 10.9 ± 5.0, respectively).

Table 1

 1 Baseline demographics and disease characteristics in the full analysis set Values are presented as the mean ± standard deviation unless otherwise stated BCVA best-corrected visual acuity, CST central subfield thickness, EMA European Medicines Agency, ETDRS Early Treatment Diabetic Retinopathy Study, IVT-AFL intravitreal aflibercept

	Characteristic	EMA-aligned	Non-EMA-aligned	Total
		label	label
	Number of patients (%)	1165 (100)	301 (100)	1466 (100)
	Age, years	78.3 ± 8.6	80.2 ± 8.3	78.7 ± 8.5
	Sex, n (%)
	Female	705 (60.5)	186 (61.8)	891 (60.8)
	Race, n (%) a,b
	White	676 (58.0)	201 (66.8)	877 (59.8)
	Black or African American	2 (0.2)	1 (0.3)	3 (0.2)
	Asian	155 (13.3)	15 (5.0)	170 (11.6)
	Indigenous	2 (0.2)	2 (0.7)	4 (0.3)
	Mixed ancestry	18 (1.5)	3 (1.0)	21 (1.4)
	Not reported	52 (4.5)	79 (26.2)	131 (8.9)
	Missing	260 (22.3)	0 (0)	260 (17.7)
	BCVA, ETDRS letters	55.1 (19.8)	51.6 (21.8)	54.3 (20.3)
	CST, lm	378 (131)	362 (107)	374 (126)
	BCVA letter score category, n (%)
	\ 35	139 (11.9)	46 (15.3)	185 (12.6)
	C 35 to \ 70	692 (59.4)	177 (58.8)	869 (59.3)
	C 70	334 (28.7)	78 (25.9)	412 (28.1)
	Primary intended treatment regimen after initial monthly injections, n (%)
	Proactive treat-and-extend	999 (85.5)	284 (94.4)	1283 (87.5)
	Proactive fixed treatment	166 (14.2)	17 (5.6)	183 (12.5)
	Mean time from diagnosis to first IVT-AFL injection,	40.7 ± 287.4	23.8 ± 159.6	37.2 ± 266.2
	days

a Data on race were not collected in France b

Table 2

 2 Mean number of intravitreal aflibercept treatments by patient group from baseline to months 6, 12, and 24 in the study eye (full analysis set, observed cases)Values are presented as the mean ± standard deviation BL baseline, EMA European Medicines Agency, IVT-AFL intravitreal aflibercept

	Patient groups	Mean number of IVT-AFL treatments
		BL to month 6	BL to month 12	BL to month 24
	EMA-aligned (n = 1165)	5.2 ± 1.4	7.4 ± 2.6	10.5 ± 4.9
	Non-EMA-aligned (n = 301)	5.9 ± 1.5	8.6 ± 2.8	12.0 ± 5.2
	Total (N = 1466)	5.3 ± 1.5	7.7 ± 2.7	10.8 ± 5.0

Ophthalmol Ther (2024) 13:725-738

ACKNOWLEDGEMENTS

The authors thank all the patients and investigators who contributed to this study.

Medical Writing, Editorial, and Other Assistance Medical writing and editorial support for the preparation of this manuscript (under the guidance of the authors) was provided by Olivia Tamburello, BSc, of ApotheCom (UK), funded by Bayer Consumer Care AG, Basel, Switzerland, in accordance with Good Publication Practice (GPP) guidance (Ann Intern Med. 2022;175:1298-1304).

Author Contributions. All authors (Jean-Franc ¸ois Korobelnik, Varun Chaudhary, Paul Mitchell, Se Woong Kang, Ramin Tadayoni, Helmut Allmeier, JinKyung Lee, Xin Zhang, Tobias Machewitz, and Clare Bailey) provided equal, substantial, intellectual contribution during the writing and revising of the manuscript, and all authors approved the final version. Tobias Machewitz was responsible for the statistical analysis.

Funding. The XTEND study was funded by Bayer AG, Berlin, Germany, and the Rapid Service Fee was funded by Bayer Consumer Care AG, Basel, Switzerland. Bayer participated in the design of the study; analysis and interpretation of the data; and development of and decision to submit the manuscript. Bayer was responsible for the conduct of the study and oversight of the collection and management of data.

Data Availability. Availability of the data underlying this publication will be determined later according to Bayer's commitment to the European Federation of Pharmaceutical Industries and Associations/Pharmaceutical Research and Manufacturers of America ''Principles for responsible clinical trial data sharing.'' This pertains to scope, time point, and process of data access. As such, Bayer commits to sharing, upon request from qualified scientific and medical researchers, patient-level clinical trial data, study-level clinical trial data, and protocols from clinical trials in patients for medicines and indications approved in the USA) and