Age-related Macular Degeneration (AMD) in the Vitamin D and Omega-3 Trial (VITAL)
Phase: NA
Conditions: Age-related Macular Degeneration
Sponsor: Brigham and Women's Hospital

Age-related Macular Degeneration (AMD) 
in the Vitamin D and Omega-3 Trial (VITAL) 
 
NCT01782352 
 
(3/29/2012)

Protocol: AMD in the VITamin D and OmegA-3 TriaL (VITAL) 
 
(Version 1: 3/29/2012) 
 
I. 
BACKGROUND AND SIGNIFICANCE 
 
Age-related macular degeneration (AMD) is the leading cause of blindness in the 
US. An estimated 1.75 million US men and women suffer from the advanced forms 
of geographic atrophy or neovascular AMD, and another 7 million are at substantial 
risk of this outcome.1 Despite advances in photodynamic2 and antivascular 
endothelial growth factor therapy3, 4 for patients with neovascular AMD, and the 
demonstration of benefit from a supplement of antioxidants plus zinc for people with 
intermediate to advanced AMD,5 vision loss from AMD remains commonplace. 
VITAL-AMD will use the resources of the VITamin D and OmegA-3 TriaL (VITAL) 
(U01 CA138962; JoAnn Manson, PI) to test the efficacy of two promising 
preventive agents in delaying the incidence and progression of AMD among 20,000 
older men and women. Vitamin D3 and omega-3 fatty acids share anti-inflammatory, 
antioxidant, antiproliferative, and antiangiogenic properties, and evidence supports 
potential benefits of both agents as strong candidates for prevention of AMD. VITAL-
AMD will have strong statistical power to address the primary (incidence) and 
secondary (progression to advanced stages) prevention of AMD. Findings from this 
study will clarify whether these agents reduce incidence and progression of AMD, 
and will provide important data for both public health and clinical guidelines for the 
primary and secondary prevention of AMD. 
 
Role of DHA+EPA in AMD - Docosahexaenoic acid (DHA) and eicosapentaenoic 
acid (EPA) are marine omega-3 polyunsaturated fatty acids that can be synthesized 
from alpha-linolenic acid, though the major source is through diet. DHA and EPA are 
important in the developing eye and visual processing. DHA is found in neural and 
vascular cell membranes and is a major structural component of photoreceptor outer 
segments.6 DHA is required for normal photoreceptor function,7 and it accounts for 
the permeability and fluidity of outer segment membranes.8, 9 DHA protects the 
vascular and neural retina from a range of stressors including reactive oxygen, 
ischemia, and inflammation, and helps promote survival of photoreceptor and RPE 
cells during phagocytosis.10 The distal tips of photoreceptor outer segments are 
intermittently shed and renewed, necessitating a constant supply of DHA and EPA. 
DHA insufficiency is associated with a delay in photoreceptor response and 
alterations in retinal structure and function that could influence the onset and 
progression of AMD.11 Supplementation with DHA and EPA appears to reverse 
these deficits12 and could have a similar beneficial effect on AMD. 
 
EPA is concentrated in the retinal vascular endothelium and in blood components13 
and has potent anti-inflammatory properties. EPA regulates lipoprotein metabolism 
and inhibits expression of several inflammatory mediators (e.g. intercellular adhesion 
molecule (ICAM)-1, monocyte chemotactic protein (MCP)-1, vascular endothelial 
growth factor (VEGF) and interleukin (IL)-6).14, 15 EPA also inhibits nuclear factor κВ 
(NF-κВ) activation, and thus expression of a number of inflammatory compounds 
that can damage the Bruch membrane and lead to AMD.16 NF-κB is a central 
regulator of IL-6, a critical regulator of CNV.15 EPA is the precursor to a group of 

eicosanoids (e.g. series-3 prostaglandins and series-5 leukotrienes) that counteract 
series-2 prostaglandins derived from arachidonic acid that promote inflammation, 
cell proliferation, and angiogenesis and interfere with immune cell function.13 EPA 
and DHA also produce resolvins, which stop infiltration and transmigration of 
polymorphonuclear leukocytes, block the production of pro-inflammatory mediators 
and regulate the trafficking of leukocytes, cells and mediators to sites of 
inflammation.17 Further, EPA depresses VEGF-specific tyrosine kinase receptor 
activation and expression,18 and with DHA may reduce neovascularization 
independent of VEGF.19 Recent work has shown that omega-3 fatty acids attenuate 
choroidal neovascularization in mice,15 and reduce or reverse retinal lesions in the 
Ccl2-/-/Cx3cr1-/- mouse model of AMD.20 Such findings are in line with 
epidemiological evidence in humans. 
 
Some cross-sectional studies have reported significant inverse associations 
between higher fish intake and risk of early21 or late AMD,22-26 while others found no 
association.27-29 Among studies examining omega-3 fatty acids, 2 studies found no 
significant relationships,21, 30 whereas 4 studies showed reduced risks of neovascular 
AMD22-24 or central geographic atrophy,25 although in 2 studies the benefit was 
restricted to those with low dietary intake of linoleic acid.22, 23 Prospective studies 
include a report on 567 incident cases of AMD from the Nurses’ Health Study (NHS) 
and Health Professionals Follow-up Study (HPFS) that showed a significant 30% 
reduction in AMD incidence with high DHA intake (RR not significant after 
adjustment for other fats).31 High intake of EPA was associated with a non-significant 
23% lower risk of AMD. In the Blue Mountains Eye Study, higher intake of omega-3 
fatty acids lowered risk of early AMD by 60% after 5 y.32 At 10 y, the reduction was 
attenuated and not significant.33 In the Melbourne Collaborative Cohort Study, higher 
omega-3 fatty acid intake reduced early AMD risk by 15%.34 In the Age-related Eye 
Disease Study (AREDS), after 6.3 y of follow-up, risks for central geographic atrophy 
were 45% & 56% lower in those with high intake of DHA & EPA, respectively.35 
Higher intakes of DHA & EPA were also associated with ~25% lower risks for 
progression to advanced AMD after 8 y follow-up in AREDS.36 At 12 y, there 
continued to be a significant ~30% reduction in risk of advanced AMD for EPA & 
DHA,37 as well as total intake of omega-3 fatty acids.38 A meta-analysis showed that 
a high intake of omega-3 fatty acids conferred a 38% risk reduction for advanced 
AMD, and fish intake ≥2x/wk was associated with 25% and 33% lower risks of early 
and advanced AMD, respectively.39 
 
We recently examined dietary intake of omega-3 fatty acids and AMD among 38,022 
women in the Women’s Health Study (WHS) who completed a dietary questionnaire 
at baseline and were free of a diagnosis of AMD. A total of 235 cases of visually 
significant AMD were confirmed during 10 y of follow-up. Women in the highest 
third of DHA intake had a 38% lower risk of AMD (RR, 0.62; 95% CI, 0.44-0.87) 
compared to those in the lowest third of intake. High intake of EPA was also 
associated with a reduced risk of AMD (RR, 0.66; 95% CI, 0.48-0.92). These 
prospective data from a large population of women appear to be the strongest 
evidence to date to support a role for DHA and EPA in the primary prevention of 
AMD.  
 

Possible Mechanisms for Vitamin D in AMD - A plausible role for vitamin D3 in 
AMD prevention can be postulated due to its immunomodulatory, anti-inflammatory, 
and antiangiogenic properties. 1,25(OH)2D interferes with the activation and 
signaling of NF-κB.40, 41 1,25(OH)2D decreases production of proinflammatory 
cytokines IL-2,42 IL-6,43 IL-8,44 and IL-12,45 increases production of the anti-
inflammatory cytokine IL-10,46 and regulates expression of matrix metalloproteinase-
9.47 Vitamin D also lowers blood levels of C-reactive protein, a marker of systemic 
inflammation that we have prospectively linked to elevated risks of AMD in the 
WHS48 and others have shown to be associated with AMD.49-52 Vitamin D is a potent 
stimulator of mechanisms for pathogen elimination, which could be relevant given 
the possible involvement of chronic infection in AMD.53 In addition, vitamin D 
regulates the renin-angiotensin-aldosterone system (RAAS) via suppression of renin 
gene expression and biosynthesis,54 and could exert an indirect beneficial effect on 
AMD through improved blood pressure control.55 Favorable effects of vitamin D on 
glucose tolerance and insulin sensitivity56, 57 could also mediate a beneficial effect in 
AMD as suggested by the association between dietary glycemic index and AMD.58-62 
 
In vitro and in vivo studies have demonstrated that 1,25(OH)2D profoundly inhibits 
growth of a variety of tumors by directly impacting the proliferation and activity of 
endothelial cells (ECs) and inhibiting angiogenesis, actions mediated by VDR.63-65 In 
the mouse oxygen-induced ischemic retinopathy (OIR) model, 1,25(OH)2D-treated 
animals demonstrated a dose-dependent reduction in retinal neovascularization, and 
inhibition of retinal EC capillary morphogenesis without a significant inhibitory effect 
on EC proliferation and migration.66 
 
To date, there are 3 studies of vitamin D and AMD, all supportive. Circulating 
25(OH)D reflects all sources of vitamin D exposure, has a half-life of 2-3 weeks, and 
is the most comprehensive and stable indicator of vitamin D status.67 Data from the 
3rd NHANES indicated that serum levels of 25(OH) D were inversely associated with 
the prevalence of early AMD (OR for extreme quintiles, 0.64, 95%CI, 0.5-0.8), but 
not advanced AMD (OR, 1.16, 95%CI, 0.5-3.1).68 Data from the Carotenoids and 
Age-Related Eye Disease Study indicated that high serum 25(OH)D status may be 
protective against intermediate AMD in women <75 y (OR for extreme quintiles, 
0.57; 95% CI, 0.33-0.99; p=0.02).69 Recent data from a monozygotic twin study with 
discordant AMD phenotypes found higher dietary intake of vitamin D in the twin with 
less severe AMD.70 
 
II. 
SPECIFIC AIMS 
 
The primary aims of this proposal are: 
 
1. Does fish oil supplementation (EPA+DHA, 1g/d), compared to placebo, reduce the 
incidence and/or progression of AMD? 
 
2. Does vitamin D3 supplementation (2000 IU/d), compared to placebo, reduce the 
incidence and/or progression of AMD? 
 
The primary aims will be addressed in analyses involving the entire VITAL cohort of 
n=20,000 older men and women.  

The secondary aims of this proposal are: 
 
3. Are there synergistic or antagonistic effects of fish oil and vitamin D3 
supplementation on the primary and secondary AMD endpoints? 
 
This secondary aim will be addressed in analyses involving the entire VITAL cohort 
of n=20,000 older men and women.  
 
4. Does baseline circulating vitamin D status modify the effect of vitamin D3 
supplementation on AMD? 
 
5. Does baseline circulating omega-3 fatty acid status modify the effect of EPA+DHA 
supplementation on AMD?  
 
Secondary aims 4 and 5 will be addressed in the subgroup which provides a 
baseline blood specimen (N~16000). 
 
6. Are there associations of polymorphisms in CYP24A1, vitamin D receptor, 
desaturase genes, or other genes with functional relevance to vitamin D and omega-
3 fatty acid pathways with incidence of AMD? 
 
7. Do polymorphisms in CYP24A1, the vitamin D receptor, complement factor H, 
ARMS2, C3, C2/BF, RORA, or other functionally relevant genes modify the effects of 
vitamin D3 on the AMD endpoints? 
 
8. Do polymorphisms in desaturase genes (FADS1, FADS2, FADS3), elongase of 
very long fatty acids 2 (ELOVL2), complement factor H, ARMS2, C3, C2/BF, RORA, 
or other functionally relevant genes modify the effects of EPA+DHA on the AMD 
endpoints? 
 
Secondary aims 6, 7, and 8 will be addressed in the subgroup which provides a 
baseline blood specimen using a nested case-control sample of all AMD cases 
(incident AMD cases and progression to advanced AMD) and a set of age- and sex-
matched controls remaining free of AMD. 
 
III. 
SUBJECT SELECTION/ENROLLMENT 
 
VITAL-AMD is an ancillary study of the NIH-funded VITAL trial. All persons 
randomized in VITAL are included in this ancillary study. 
 
Individuals are eligible for VITAL trial participation if they meet the following criteria: 
(1) are age ≥60 (men) or ≥65 (women); (2) have at least a high school education (to 
complete mail-based questionnaires); (3) have no history of cancer (except non-
melanoma skin cancer), MI, stroke, TIA, angina pectoris, CABG, or PCI; (4) have 
none of the following safety exclusions: history of kidney stones, renal failure or 
dialysis, hypercalcemia, hypo-or hyperparathyroidism, severe liver disease 
(cirrhosis), or sarcoidosis or other granulomatous diseases such as active chronic 
tuberculosis or Wegener’s granulomatosis; (5) have no allergy to fish (for 
EPA+DHA); (6) have no other serious illness that would preclude participation; (7) 

are consuming no more than 800 IU of vitamin D from all supplemental sources 
combined (individual vitamin D supplements, calcium+vitamin D supplements, 
medications with vitamin D [e.g., Fosamax Plus D], and multivitamins), or, if taking, 
willing to decrease or forego such use during the trial (to ensure the overall dose is 
well below the no-observed-adverse effect level (NOAEL) of 4000 IU specified by the 
European Commission Scientific Committee on Food (ECSCF); (8) are consuming 
no more than 1200 mg/d of calcium (the RDA) from all supplemental sources 
combined, or, if taking, willing to decrease or forego such use during the trial; (9) are 
not taking fish oil supplements, or, if taking, willing to forego their use during the trial; 
and (10) are willing to participate, as evidenced by signing the informed consent 
form. 
 
IV. 
STUDY PROCEDURES 
 
The procedures used to ascertain and document self-reports of AMD in VITAL-AMD 
are modeled on those used for more than two decades by the PIs in Physicians’ 
Health Study I and II, Women’s Health Study, and Women’s Antioxidant Folic Acid 
Cardiovascular Study. All information is obtained masked to randomization status. 
Baseline and follow-up questionnaires are sent to study participants annually to 
obtain reports of diagnoses of AMD. Non-respondents are sent additional requests 
and are finally called to ensure complete follow-up. Reports of AMD may also be 
received through letters or telephone calls. Following the report of AMD, we obtain 
written consent to identify the diagnosing eye doctor(s) and obtain medical record 
information. We will contact the eye doctor(s) by mail and request they complete an 
AMD questionnaire or forward a complete copy of the patient’s medical records 
pertaining to the diagnosis of AMD. 
 
AMD questionnaire - The AMD questionnaire asks about the date of initial 
diagnosis of AMD, the best-corrected visual acuity (VA) at the time of diagnosis, the 
date when VA reached 20/30 or worse, the most recent VA, and information about 
the pathological findings observed on exam (drusen, RPE hypo- &/or 
hyperpigmentation, geographic atrophy, RPE detachment, subretinal neovascular 
membrane, or disciform scar). The questionnaire will inquire about drusen size 
(small, intermediate, large) as well as information on the location of geographic 
atrophy (central versus noncentral). We will obtain information on treatments for 
AMD (laser, photodynamic, or anti-VEGF therapy). We will also obtain information 
about whether there are other ocular abnormalities that could explain or contribute to 
visual loss. If so, the eye doctor is asked to provide his/her judgment as to whether 
AMD, by itself, is significant enough to cause VA of 20/30 or worse. Once obtained, 
the medical record information will be evaluated by a single reviewer (Dr. Christen), 
masked to the treatment assignments, to determine conformity with uniform 
diagnostic criteria. In cases of uncertainty, Dr. Schaumberg will also review the 
records. Reports for which doctors indicate diagnostic uncertainty will not be 
included as cases. When other ocular pathology is present, we will not include the 
case in our visually-significant AMD case group unless the examining eye doctor 
indicates their judgment that the AMD by itself would be sufficient to result in VA of 
20/30 or worse. We define neovascular AMD by presence of RPE detachment, 
subretinal neovascular membrane, or disciform scar, either from clinical exam, 

photos, or OCT if available, and will document the date of diagnosis of neovascular 
AMD. 
 
Fundus Photographs - In order to obtain the highest quality endpoints possible in 
VITAL-AMD, we will obtain standard fundus photographs (e.g. 30° color 
photographs centered on the macula) of each eye from all participants for whom we 
confirm a diagnosis of AMD by review of medical records. In our recent experience, 
nearly all cases of neovascular AMD have photographs, angiograms, or OCTs 
available as part of routine care, however, dry AMD cases may not have photos. We 
will take the following steps to obtain photos for each prevalent case at baseline and 
for all incident cases: 1) When we obtain the medical record information, we will 
request copies of fundus photos centered on the macula for both eyes if available, or 
if not available we will ask whether the doctor would be willing and able to obtain a 
new set of photos for VITAL-AMD. 2) Study participants who do not already have 
photos in their medical records will be asked whether they would be willing to have 
photos taken (we have received funds to reimburse clinics for taking and sending 
photographs for VITAL participants with AMD), 3) If the participant’s own doctor is 
not willing or able to take a set of photographs (e.g. s/he doesn’t have the 
equipment), we will assist participants to obtain photographs from a doctor near their 
home. We will use databases (e.g. the Academy of Ophthalmology maintains a list 
by subspecialty) to search for retina specialists or other eye doctors with offices near 
the study participant and ascertain their willingness to take a set of photos for 
VITAL-AMD. 4) At the end of the trial, we will obtain a 2nd set of photos from all 
cases who remain alive and for whom we have not already documented progression 
to advanced AMD. 5) We will use the simplified AREDS scale to evaluate the 
photographs (grading will be done masked to randomization status). 
 
Assessment of AMD progression. - We will send an annual follow-up 
questionnaire to all participants with medical-record confirmed AMD to ascertain 
progression to advanced AMD. The questionnaire will ask about changes in the 
participant’s vision, and any updates on their diagnosis of AMD (e.g. the 
development of the "wet" form, any treatments received [e.g. anti-VEGF therapy], 
etc.). We will obtain follow-up medical records from all cases in which we suspect 
progression may have occurred. We will also routinely obtain follow-up records every 
two years from all participants with confirmed AMD that has not yet progressed to 
advanced AMD to help ensure no cases of progression are missed. Finally, we will 
also obtain a second set of retinal photographs at the end of the trial and grade 
these using the simplified AREDS scale. Progression along the simplified AREDS 
scale will be ascertained during analysis by comparison of the final grade with the 
baseline grade. 
 
Validity of medical record-confirmed incident AMD - At initiation of VITAL-AMD 
we will conduct a pilot study to further validate our methodology for collection of 
photographs and to estimate sensitivity of case detection in the VITAL population. 
We will immediately seek to obtain informed consent for review of eye exam records 
and retinal photographs from a sample of 500 randomly selected VITAL participants 
at baseline. We will review medical records and photos masked to both randomized 
treatment assignments as well as the participants’ response to the question about a 
prior diagnosis of AMD. We will estimate sensitivity based on the proportion of true 

positives, that is the proportion of true AMD cases (identified by reviewing medical 
records and photos) that we identified using our methodology for AMD case 
identification (i.e. those that reported AMD on the baseline questionnaire that were 
confirmed by review of medical records). With estimated baseline prevalence of 
AMD=0.07 we will be able to estimate sensitivity with a 95% CI of ±15%. If sensitivity 
is found to be too low (e.g. <65%), we will consider strategies for increasing case 
detection in VITAL-AMD, for example by increasing participant awareness of AMD 
and the importance of eye exams for its detection, e.g. through participant 
newsletters. 
 
V. 
BIOSTATISTICAL ANALYSIS 
 
Assuming annual event rates for AMD observed in our previous trials of men and 
women, and an average follow-up of 6 years (expected for VITAL), VITAL-AMD will 
have good (≥80%) to excellent (≥95%) power to detect reductions of ≥20% in the 
primary AMD endpoint. 
 
The study design is a 2x2 factorial randomized trial. With the large sample size, 
randomization should assure an equal distribution of known and unknown 
confounders between treatment groups, but we will control in analysis for any 
chance imbalances that may occur for AMD risk factors or conditions requiring more 
frequent medical attention that could increase the likelihood of AMD diagnosis. 
We will estimate the main treatment effects using the intention-to-treat principle 
based on randomized treatment assignment. Initial analyses of primary and 
secondary AMD endpoints will include contingency tables in which the rate of each 
endpoint (number of events per person-year of observation) among participants 
allocated to active treatment will be compared with the rate among those allocated to 
its placebo; controlling by stratification for the other treatment assignment. In 
addition, Kaplan-Meier survival estimates, the logrank test, and proportional hazards 
regression models201 will be used to determine whether there is a difference in time 
to an AMD event. Because an extended exposure to the study agents may be 
required to observe an effect, we will also conduct analyses which exclude AMD 
events that occur during the early years after randomization. To address the issue of 
AMD ascertainment, we will also test associations in models where the at-risk 
population during each 1 y follow-up period is restricted to those who report having 
had an eye exam during that year. 
 
We will examine effect modification by the other randomized intervention, by 
race/skin pigmentation (for vitamin D), and by other risk factors by including an 
interaction term in proportional hazards models, as well as using methods for testing 
additive interactions. Stored blood samples will be used to measure genetic 
polymorphisms and analyses will examine the effect of these polymorphisms on the 
AMD endpoints, as well as modification of the treatment effects. These analyses will 
be analyzed as a nested case-control study using multivariable conditional logistic 
regression analyses and will also include testing of interactions on the additive scale. 
 
VI. 
RISKS AND DISCOMFORTS 
 

The only possible risk in this study involves the social/psychological risk that could 
result from inadvertent disclosure of confidential information from the questionnaires 
or blood tests. However, we have many safeguards in place to avoid this possibility, 
and we have never had an inadvertent breach of confidentiality in any of our trials. 
Confidentiality of participants is secured via locked file cabinets, use of participant ID 
numbers, and restrictions on access to computerized records and use or release of 
both individual and aggregate VITAL participant data, including randomized 
treatment assignments, in publications and presentations. Access to the VITAL 
databases and certain network files is restricted to essential staff only, and is 
protected by passwords and restricted access accounts. All blood specimens sent to 
the laboratories for analysis will be labeled with an ID number only, so that no 
individual identifying information will be made available in any form to these sites. In 
addition, employees involved with the proposed study will be asked to sign a form 
agreeing not to disclose any information to which they might have access, 
regardless of their personal perception about its confidentiality. 
 
There is no additional risk to participation in VITAL-AMD beyond that incurred by 
participants as part of their regular activities in VITAL. All participants will have 
agreed by signing their VITAL consent form that their blood and other relevant data 
will be stored for future analyses and that they would not learn of the results of those 
analyses.  
 
VII. 
POTENTIAL BENEFITS 
 
For the majority of participants, there will be few direct benefits from participating in 
this primary prevention study other than the awareness of being involved in a large 
endeavor to answer relevant and timely questions regarding the possible benefits of 
vitamin D and marine omega-3 fatty acids. The potential benefits to society relate to 
the increasing use of both vitamin D and fish oil for many health purposes, with data 
not yet clearly indicating either clear benefit or harm. This study will provide a wealth 
of data on the effects of these supplements on risk of AMD, the leading cause of 
blindness in the United States, and will help guide individual decisions, clinical 
recommendations, and public health guidelines. 
 
VIII. 
MONITORING AND QUALITY ASSURANCE 
 
As Co-PIs, Dr. William Christen and Dr. Debra Schaumberg will be responsible for 
monitoring data collection and assuring the validity and integrity of the data and 
adherence to the IRB-approved protocol. 
 
A VITAL Data and Safety Monitoring Board (DSMB) has been created as an 
independent body charged with ensuring that the safety of participants is protected 
and that the scientific goals of the study are being met. The VITAL DSMB is charged 
with monitoring differences by treatment agent of ancillary study outcomes, including 
AMD, and will be empowered to terminate the trial based on evidence of substantial 
harm or benefit. To support those purposes, the DSMB will review any proposed 
amendments to the study protocol, examine the progress of the trial and the 
unblinded data on study endpoints, perform expedited review of all serious adverse 

events (i.e., events meeting the FDA definition of Serious Adverse Events, such as 
any fatal event including suicide, immediately life-threatening event, or permanently 
or substantially disabling event), perform ongoing monitoring of drop-outs and non-
serious adverse events, determine whether study procedures should be changed or 
the study should be halted for reasons related to the safety of participants, and 
perform periodic review of the completeness and validity of data to be used for 
analysis of safety and efficacy. The DSMB will also ensure participant privacy and 
research data confidentiality. The DSMB will employ monitoring rules71, 72 that will 
serve solely as guidelines in decisions regarding continuation or stopping of 
treatment arms. While these rules are intended for the primary endpoints of VITAL 
(primary prevention of cancer and CVD), the DSMB will also consider secondary and 
ancillary VITAL endpoints (including AMD) in assessing the overall balance of 
benefits and risks of the two agents. All decisions must be made after examining the 
totality of evidence, including other trial data, on these agents. All decisions will be 
made after examining the totality of evidence, including other trial data, on these 
agents. 
 
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