A Study to Compare the Efficacy and Safety of Luspatercept (ACE-536) Versus Epoetin Alfa for the Treatment of Anemia Due to IPSS-R Very Low, Low, or Intermediate Risk Myelodysplastic Syndromes (MDS) Participants Who Require Red Blood Cell Transfusions and Are ESA Naïve
- Conditions
- Myelodysplastic Syndromes
- Interventions
- Registration Number
- NCT03682536
- Lead Sponsor
- Celgene
- Brief Summary
The purpose of this study is to determine the effectiveness of luspatercept (ACE-536) compared to epoetin alfa on red blood cell (RBC) transfusion independence (for at least 12 weeks) with a concurrent hemoglobin increase of at least 1.5 g/dL in participants with anemia due to revised international prognostic scoring system (IPSS-R) very low, low, or intermediate risk myelodysplastic syndromes (MDS) who require RBC transfusions and have never been exposed to erythropoiesis stimulating agent (ESA).
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 363
- Documented diagnosis of Myelodysplastic syndromes (MDS) according to WHO 2016 classification that meets revised international prognostic scoring system (IPSS-R) classification of very low, low, or intermediate risk disease, and have < 5% blasts in bone marrow
- Endogenous serum erythropoietin (sEPO) level of < 500 U/L
- Requires Red blood cell (RBC) transfusions, as documented by the criteria: Average transfusion requirement of 2 - 6 units/8 weeks of packed red blood cells (pRBCs) confirmed for a minimum of 8 weeks immediately preceding randomization
- Eastern Cooperative Oncology Group (ECOG) score of 0, 1, or 2
- Clinically significant anemia due to iron, vitamin B12, or folate deficiencies, or autoimmune or hereditary hemolytic anemia, or hypothyroidism, or any type of known clinically significant bleeding or sequestration or drug induced anemia
- Known history of diagnosis of Acute myeloid leukemia (AML)
- Uncontrolled hypertension, defined as repeated elevations of systolic blood pressure (SBP) of ≥ 150 mmHg and/or diastolic blood pressure (DBP) ≥ 100 mmHg despite adequate treatment
Other protocol-defined inclusion/exclusion criteria apply
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Luspatercept Luspatercept - Epoetin alfa Epoetin alfa -
- Primary Outcome Measures
Name Time Method Percentage of Participants With Red Blood Cell Transfusion Independence (RBC-TI) for 12 Weeks (84 Days) With a Mean Hemoglobin Increase ≥ 1.5 g/dL Week 1 through Week 24 Percentage of participants who are RBC transfusion-free for any 12-week period associated with a concurrent mean hemoglobin (Hgb) increase ≥ 1.5 g/dL compared to baseline.
After applying below 14/3-day rule, the baseline Hgb value is defined as the lowest Hgb value from the central, local laboratory, or pre transfusion Hgb from transfusion records that is within 56 days on or prior to the first dose of treatment, or randomization date if participants were not treated.
4/3-day rule: only Hgb values that are at least 14 days after a transfusion may be used unless there is another transfusion within 3 days after the Hgb assessment. If this occurs, that Hgb value will be used despite being \< 14 days after the previous transfusion.
- Secondary Outcome Measures
Name Time Method Percentage of Participants With Red Blood Cell Transfusion Independence (RBC-TI) for 24 Weeks Week 1 through Week 24 Red blood cell transfusion independence (RBC-TI) for 24 weeks is defined as the percentage of participants who did not receive RBC transfusions from Week 1 through Week 24.
Mean Hemoglobin Change Over 24 Weeks Week 1 through Week 24 Mean hemoglobin (Hgb) change over the 24-week period of Week 1 through Week 24 compared to baseline.
After applying below 14/3-day rule, the baseline Hgb value is defined as the lowest Hgb value from the central, local laboratory, or pre transfusion Hgb from transfusion records that is within 56 days on or prior to the first dose of treatment, or randomization date if participants were not treated.
4/3-day rule: only Hgb values that are at least 14 days after a transfusion may be used unless there is another transfusion within 3 days after the Hgb assessment. If this occurs, that Hgb value will be used despite being \< 14 days after the previous transfusion.Percentage of Participants Achieving Red Blood Cell Transfusion Independence (RBC-TI) for ≥ 12 Weeks (84 Days) Week 1 through Week 24 Percentage of participants who are RBC transfusion-free over a consecutive 84-day period.
Percentage of Participants Achieving Hematologic Improvement - Erythroid Response (HI-E) Per IWG Week 1 through Week 24 The percentage of participants meeting the modified HI-E criteria per the International Working Group (IWG) sustained over any consecutive 56-day period in Week 1-24: For participants with baseline red blood cell (RBC) transfusion burden of \>= 4 units/8 weeks, a reduction of at least 4 units RBC transfusion; for participants with baseline RBC transfusion burden of \< 4 units/8 weeks, mean increase of hemoglobin of at least 1.5 g/dL in the absence of transfusions.
The Number of Participants With Adverse Events (AEs) From first dose to 42 days post last dose (Up to approximately an average of 72 weeks and a maximum of 208 weeks) Treatment-emergent adverse events include adverse events that started on or after the first dose of treatment until 42 days after the last dose of treatment, as well as those serious adverse events (SAEs) made known to the investigator at any time thereafter that are suspected of being related to treatment.
The severity/intensity of AEs were graded according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE, Version 4.0). Grade 3 = Severe, Grade 4 = Life-threatening, and Grade 5 = Death.Time to Red Blood Cell Transfusion Independence (RBC-TI) ≥ 12 Weeks (84 Days) Week 1 through Week 24 Time from first dose to first onset of transfusion independence ≥ 84 days.
Number of Participants With a Positive Anti-drug Antibody (ADA) Test Day 1 on week 4, 10, 16, 22, and every 12 weeks (±14 days) from the 24-Week MDS Assessment visit for up to one year from the first dose Number of participants under each ADA positive category. A participant is counted as 'Treatment-Emergent' if there is a positive post-baseline sample while the baseline sample is ADA negative, or there is a positive post-baseline sample with a titer \>= 4-fold of the baseline titer while the baseline sample is ADA positive. A participant is counted as 'Preexisting' if the baseline sample is ADA positive and the participant is not qualified for 'Treatment-Emergent'. If the participant was discontinued from study treatment earlier than one year from the first dose, additional samples will be collected if last ADA is positive.
Baseline is defined as the last value on or before the first dose of study drug.Time to Hematologic Improvement - Erythroid Response (HI-E) Week 1 through Week 24 Time from first dose to first onset of achieving modified HI-E.
The modified HI-E criteria per the International Working Group (IWG) sustained over any consecutive 56-day period in Week 1-24: For participants with baseline red blood cell (RBC) transfusion burden of \>= 4 units/8 weeks, a reduction of at least 4 units RBC transfusion; for participants with baseline RBC transfusion burden of \< 4 units/8 weeks, mean increase of hemoglobin of at least 1.5 g/dL in the absence of transfusions.The Number of Red Blood Cell (RBC) Units Transfused Within the First 24 Weeks of Treatment Week 1 through Week 24 RBC transfusion burden on treatment is defined as total number of packed red blood cell (pRBC) units transfused within the first 24 weeks of treatment since Week 1.
Time to First Red Blood Cell (RBC) Transfusion Week 1 through End of Treatment (Up to approximately an average of 66 weeks and a maximum of 202 weeks) Time to first RBC transfusion is defined as time from Week 1 to first RBC transfusion on treatment. Participants who maintain RBC-TI through the end of the Treatment Period or time of analysis will be censored at EOT visit date, subsequent MDS therapy start date, study discontinuation date, analysis cutoff date or death, whichever occurs first. Median is from un-stratified Kaplan-Meier method.
Percentage of Participants Achieving Red Blood Cell Transfusion Independence (RBC-TI) for ≥ 56 Days (8 Weeks) Week 1 through Week 24 Defined as percentage of participants achieving RBC-TI for \>= 56 days during any consecutive 56-day period from Week 1 through Week 24.
Percentage of Participants Achieving Red Blood Cell Transfusion Independence (RBC-TI) for a Consecutive 24-week Period Week 1 through Week 48 Defined as percentage of participants achieving RBC-TI for \>= 168 days during any consecutive 168-day period from Week 1 through Week 48.
Duration of Red Blood Cell Transfusion Independence (RBC-TI) ≥ 12 Weeks (84 Days) Week 1 through End of Treatment (Up to approximately an average of 66 weeks and a maximum of 202 weeks) Maximum duration of RBC transfusion independence for participants who achieve RBC-TI ≥ 84 days.
The Number of Participants With Acute Myeloid Leukemia (AML) Progression From randomization to 5 years from first dose or 3 years from last dose (whichever occurs later), unless the participant withdraws consent from the study, dies or is lost to follow-up. (Up to approximately 221 weeks) Progression to AML is defined as a diagnosis of AML as per WHO classification of ≥ 20% blasts in peripheral blood or bone marrow.
Median Time to Acute Myeloid Leukemia (AML) Progression From randomization to first diagnosis of AML up to 5 years from first dose or 3 years from last dose (whichever occurs later), unless the participant withdraws consent from the study, dies or is lost to follow-up. (Up to approximately 221 weeks) Time to AML progression is defined as the time between randomization and first diagnosis of AML as per WHO classification of ≥ 20% blasts in peripheral blood or bone marrow. Participants with diagnosis of AML will be considered to have had an event. Participants who have not progressed to AML at the time of analysis will be censored at the last assessment date which does not indicate progression to AML estimated by Kaplan-Meier method.
Overall Survival (OS) Randomization to death due to any cause up to 5 years from first dose or 3 years from last dose (whichever occurs later), unless the participant withdraws consent from the study, dies or is lost to follow-up. (Up to approximately 221 weeks) Time from date of randomization to death due to any cause
Change From Baseline in the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (EORTC QLQ-C30) Baseline and week 24. The EORTC QLQ-C30 is composed of 30 items that includes a global health status score ranging from: 1-7 as well as scores for 5 functional scales (physical, role, emotional, cognitive and social), 3 symptom scales (fatigue, nausea/vomiting, and pain) and 6 single items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties) all ranging from 1-4. Subscale scores are transformed to a 0 to 100 scale. A high score for a functional scale represents a high or healthy level of functioning; a high score for the global health status/health related quality of life (HRQoL) represents a high overall HRQoL; but a high score for a symptom scale represents a high level of symptomatology or problems. Baseline is defined as the last value on or before the first dose of study drug.
Area Under the Concentration-time Curve [AUC] Day 1 on week 4, 10, 16, 22, and every 12 weeks (±14 days) from the 24-Week MDS Assessment visit for up to one year from the first dose Maximum Plasma Concentration of Drug [Cmax] Day 1 on week 4, 10, 16, 22, and every 12 weeks (±14 days) from the 24-Week MDS Assessment visit for up to one year from the first dose Change From Baseline in the Functional Assessment of Cancer Therapy-Anemia Version 4 (FACT-An) Baseline, Day 1 on weeks 7,13,19, and 24. The Functional Assessment of Cancer Therapy - Anemia (FACT-An) questionnaire includes 47 items rating on a 5-point Likert scale from 0 (not at all) to 4 (very much) (so that 0 is considered worse quality of life and 4 is good response) on five primary subscales:
* Physical well-being (sum of 7 items, score range from 0-28)
* Social/Family well-being (sum of 7 items, score range from 0-28)
* Emotional well-being (sum of 6 items, score range from 0-24)
* Functional well-being (sum of 7 items, score range from 0-28)
* Anemia-related symptoms (sum of 20 items, score range from 0-80)
A total score for the FACT-An can be calculated by summing the five primary subscales with a score range from 0-188. Higher scores representing better quality of life. Baseline is defined as the last value on or before the first dose of study drug.
Trial Locations
- Locations (226)
Local Institution - 114
🇺🇸Salt Lake City, Utah, United States
Local Institution - 107
🇺🇸Berkeley, California, United States
Local Institution - 115
🇺🇸San Diego, California, United States
Local Institution - 101
🇺🇸Whittier, California, United States
Local Institution - 104
🇺🇸New Haven, Connecticut, United States
Local Institution - 136
🇺🇸Washington, District of Columbia, United States
Local Institution - 119
🇺🇸Hudson, Florida, United States
Local Institution - 120
🇺🇸Saint Petersburg, Florida, United States
Local Institution - 122
🇺🇸Tallahassee, Florida, United States
Local Institution - 108
🇺🇸Tampa, Florida, United States
Local Institution - 118
🇺🇸West Palm Beach, Florida, United States
Local Institution - 102
🇺🇸Paducah, Kentucky, United States
Local Institution - 123
🇺🇸Bethesda, Maryland, United States
Local Institution - 117
🇺🇸Kansas City, Missouri, United States
Local Institution - 134
🇺🇸East Brunswick, New Jersey, United States
Local Institution - 113
🇺🇸Hackensack, New Jersey, United States
Local Institution - 105
🇺🇸Greenville, North Carolina, United States
Local Institution - 131
🇺🇸Portland, Oregon, United States
Univ of Pittsburgh Medical Center
🇺🇸Pittsburgh, Pennsylvania, United States
Local Institution - 111
🇺🇸Rock Hill, South Carolina, United States
Tennessee Oncology
🇺🇸Nashville, Tennessee, United States
Baylor University Medical Center
🇺🇸Dallas, Texas, United States
Local Institution - 109
🇺🇸Houston, Texas, United States
Local Institution - 132
🇺🇸Charlottesville, Virginia, United States
Local Institution - 127
🇺🇸Chesapeake, Virginia, United States
Local Institution - 206
🇦🇺Albury, New South Wales, Australia
Local Institution - 213
🇦🇺Blacktown, New South Wales, Australia
Local Institution - 200
🇦🇺Concord, New South Wales, Australia
Local Institution - 215
🇦🇺Kogarah, New South Wales, Australia
Local Institution - 211
🇦🇺Nowra, New South Wales, Australia
Local Institution - 210
🇦🇺Waratah, New South Wales, Australia
Local Institution - 207
🇦🇺Wollongong, New South Wales, Australia
Local Institution - 208
🇦🇺Auchenflower, Queensland, Australia
Local Institution - 202
🇦🇺Adelaide, South Australia, Australia
Local Institution - 204
🇦🇺Clayton, Victoria, Australia
Local Institution - 203
🇦🇺Malvern, Victoria, Australia
Local Institution - 209
🇦🇺Melbourne, Victoria, Australia
Local Institution - 205
🇦🇺West Perth, Western Australia, Australia
Local Institution - 212
🇦🇺Randwick, Australia
Local Institution - 442
🇦🇹Linz, Austria
Local Institution - 441
🇦🇹Vienna, Austria
Local Institution - 475
🇧🇪Antwerpen, Belgium
Local Institution - 471
🇧🇪Brasschaat, Belgium
Local Institution - 474
🇧🇪Brussels, Belgium
Local Institution - 472
🇧🇪Charleroi, Belgium
Local Institution - 473
🇧🇪Kortrijk, Belgium
Local Institution - 470
🇧🇪Leuven, Belgium
Local Institution - 476
🇧🇪Roeselare, Belgium
Local Institution - 147
🇨🇦Calgary, Alberta, Canada
Local Institution - 145
🇨🇦Edmonton, Alberta, Canada
Local Institution - 142
🇨🇦Hamilton, Ontario, Canada
Local Institution - 140
🇨🇦Ottawa, Ontario, Canada
Local Institution - 141
🇨🇦Toronto, Ontario, Canada
Local Institution - 144
🇨🇦Montreal, Quebec, Canada
Local Institution - 148
🇨🇦Montreal, Quebec, Canada
Local Institution - 151
🇨🇦Saskatoon, Saskatchewan, Canada
Local Institution - 152
🇨🇦Sherbrooke, Canada
Local Institution - 560
🇨🇿Hradec Kralove, Czechia
Local Institution - 564
🇨🇿Ostrava-Poruba, Czechia
Local Institution - 563
🇨🇿Prague 10, Czechia
Local Institution - 562
🇨🇿Praha 2, Czechia
Local Institution - 561
🇨🇿Praha, Czechia
Local Institution - 317
🇫🇷Angers, France
Local Institution - 312
🇫🇷Bayonne, France
Local Institution - 311
🇫🇷Caen Cedex 9, France
Local Institution - 306
🇫🇷La Tronche, France
Local Institution - 305
🇫🇷Le Mans, France
Local Institution - 309
🇫🇷Lille, France
Local Institution - 303
🇫🇷Limoges Cedex, France
Local Institution - 307
🇫🇷Nantes Cedex 01, France
Local Institution - 301
🇫🇷Nice Cedex 3, France
Local Institution - 302
🇫🇷Paris, France
Local Institution - 313
🇫🇷Paris, France
Local Institution - 308
🇫🇷Pessac, France
Local Institution - 315
🇫🇷Pierre Bénite, France
Local Institution - 316
🇫🇷Poitiers, France
Local Institution - 314
🇫🇷Strasbourg, France
Local Institution - 300
🇫🇷Toulouse, France
Local Institution - 310
🇫🇷Tours cedex, France
Local Institution - 304
🇫🇷Vandoeuvre les Nancy, France
Local Institution - 422
🇩🇪Baden-Warttemberg, Germany
Local Institution - 424
🇩🇪Berlin, Germany
Local Institution - 426
🇩🇪Dresden, Germany
Local Institution - 429
🇩🇪Duisburg, Germany
Local Institution - 420
🇩🇪Dusseldorf, Germany
Local Institution - 431
🇩🇪Hamburg, Germany
Local Institution - 435
🇩🇪Keil, Germany
Local Institution - 423
🇩🇪Koblenz, Germany
Local Institution - 428
🇩🇪Köln, Germany
Local Institution - 430
🇩🇪Leipzig, Germany
Local Institution - 436
🇩🇪Mannheim, Germany
Local Institution - 421
🇩🇪Munchen, Germany
Local Institution - 425
🇩🇪Winnenden, Germany
Local Institution - 427
🇩🇪Würzburg, Germany
Local Institution - 389
🇬🇷Heraklion, Irakleio, Greece
Local Institution - 396
🇬🇷Alexandroupolis, Greece
Local Institution - 397
🇬🇷Athens, Greece
Local Institution - 391
🇬🇷Athens, Greece
Local Institution - 392
🇬🇷Athens, Greece
Local Institution - 395
🇬🇷Athina, Greece
Local Institution - 398
🇬🇷Patras, Greece
Local Institution - 393
🇬🇷Rio Patras, Greece
Local Institution - 399
🇬🇷Thessaloniki, Greece
Local Institution - 390
🇬🇷Thessaloniki, Greece
Local Institution - 535
🇭🇺Budapest, Hungary
Local Institution - 534
🇭🇺Debrecen, Hungary
Local Institution - 536
🇭🇺Nyiregyhaza, Hungary
Local Institution - 386
🇮🇱Haifa, Israel
Local Institution - 383
🇮🇱Jerusalem, Israel
Local Institution - 384
🇮🇱Jerusalem, Israel
Local Institution - 381
🇮🇱Kfar-Saba, Israel
Local Institution - 385
🇮🇱Nahariya, Israel
Local Institution - 382
🇮🇱Tel Aviv, Israel
Local Institution - 380
🇮🇱Zerifin, Israel
Local Institution - 331
🇮🇹Orbassano, TO, Italy
Local Institution - 324
🇮🇹Bologna, Italy
Local Institution - 327
🇮🇹Firenze, Italy
Local Institution - 330
🇮🇹Meldola, Italy
Local Institution - 321
🇮🇹Milano, Italy
Local Institution - 329
🇮🇹Padova, Italy
Local Institution - 326
🇮🇹Reggio Di Calabria, Italy
Local Institution - 328
🇮🇹Roma, Italy
Local Institution - 332
🇮🇹Roma, Italy
Local Institution - 325
🇮🇹Rome, Italy
Local Institution - 323
🇮🇹Rozzano, Italy
Local Institution - 322
🇮🇹Udine, Italy
Local Institution - 238
🇯🇵Matsuyama, Ehime, Japan
Local Institution - 244
🇯🇵Nagasaki-shi, Nagasaki, Japan
Local Institution - 236
🇯🇵Osakasayama, Osaka, Japan
Local Institution - 247
🇯🇵Amagasaki-Shi, Japan
Local Institution - 249
🇯🇵Fujisawa-Shi, Japan
Local Institution - 234
🇯🇵Fukuoka, Japan
Local Institution - 237
🇯🇵Hitachi, Ibaraki, Japan
Local Institution - 231
🇯🇵Kamogawa, Japan
Local Institution - 248
🇯🇵Kitakyushu-Shi, Japan
Local Institution - 270
🇯🇵Nagaoka-Shi, Japan
Local Institution - 243
🇯🇵Nagoya-shi, Japan
Local Institution - 241
🇯🇵Ogaki, Japan
Local Institution - 235
🇯🇵Okayama, Japan
Local Institution - 242
🇯🇵Osaka, Japan
Local Institution - 233
🇯🇵Sagamihara, Japan
Local Institution - 246
🇯🇵Sapporo-shi, Japan
Local Institution - 239
🇯🇵Sendai, Japan
Local Institution - 232
🇯🇵Shibuya-ku, Japan
Local Institution - 245
🇯🇵Shimotsuga-gun, Japan
Local Institution - 230
🇯🇵Shinagawa-ku, Tokyo, Japan
Local Institution - 251
🇰🇷Busan, Korea, Republic of
Local Institution - 257
🇰🇷Daegu, Korea, Republic of
Local Institution - 250
🇰🇷Hwasun-Gun, Korea, Republic of
Local Institution - 253
🇰🇷Seongnamsi, Korea, Republic of
Local Institution - 252
🇰🇷Seoul, Korea, Republic of
Local Institution - 256
🇰🇷Seoul, Korea, Republic of
Local Institution - 255
🇰🇷Seoul, Korea, Republic of
Local Institution - 254
🇰🇷Seoul, Korea, Republic of
Local Institution - 540
🇱🇹Kaunas, Lithuania
Local Institution - 541
🇱🇹Vilnius, Lithuania
Local Institution - 462
🇳🇱Amsterdam, Netherlands
Local Institution - 461
🇳🇱Den Haag, Netherlands
Local Institution - 464
🇳🇱Nijmegen, Netherlands
Local Institution - 460
🇳🇱Rotterdam, Netherlands
Local Institution - 463
🇳🇱Sittard-Geleen, Netherlands
Local Institution - 570
🇵🇱Lodz, Lódzkie, Poland
Local Institution - 575
🇵🇱Gdansk, Poland
Local Institution - 572
🇵🇱Lubin, Poland
Local Institution - 576
🇵🇱Poznan, Poland
Local Institution - 573
🇵🇱Rzwszow, Poland
Local Institution - 579
🇵🇱Slupsk, Poland
Local Institution - 578
🇵🇱Walbrzych, Poland
Local Institution - 577
🇵🇱Wroclaw, Poland
Local Institution - 571
🇵🇱Wroclaw, Poland
Local Institution - 373
🇵🇹Beja, Portugal
Local Institution - 371
🇵🇹Braga, Portugal
Local Institution - 372
🇵🇹Lisboa, Portugal
Local Institution - 370
🇵🇹Porto, Portugal
Local Institution - 374
🇵🇹Setubal, Portugal
Local Institution - 511
🇷🇺Kaluga, Russian Federation
Local Institution - 505
🇷🇺Kirov, Russian Federation
Local Institution - 509
🇷🇺Krasnoyarsk, Russian Federation
Local Institution - 504
🇷🇺Moscow, Russian Federation
Local Institution - 507
🇷🇺Moscow, Russian Federation
Local Institution - 500
🇷🇺Moscow, Russian Federation
Local Institution - 503
🇷🇺Moscow, Russian Federation
Local Institution - 508
🇷🇺Saratov, Russian Federation
Local Institution - 506
🇷🇺St Petersburg, Russian Federation
Local Institution - 510
🇷🇺St. Petersburg, Russian Federation
Local Institution - 502
🇷🇺Tula, Russian Federation
Local Institution - 358
🇪🇸Barcelona, Spain
Local Institution - 350
🇪🇸Barcelona, Spain
Local Institution - 354
🇪🇸Granada, Spain
Local Institution - 352
🇪🇸Madrid, Spain
Local Institution - 355
🇪🇸Madrid, Spain
Local Institution - 353
🇪🇸Malaga, Spain
Local Institution - 361
🇪🇸Murcia, Spain
Local Institution - 356
🇪🇸Ourense, Spain
Local Institution - 363
🇪🇸Oviedo, Spain
Local Institution - 362
🇪🇸Palma de Mallorca, Spain
Local Institution - 351
🇪🇸Salamanca, Spain
Local Institution - 360
🇪🇸Seville, Spain
Local Institution - 357
🇪🇸Valencia, Spain
Local Institution - 359
🇪🇸Valencia, Spain
Local Institution - 550
🇸🇪Goteborg, Sweden
Local Institution - 552
🇸🇪Lund, Sweden
Local Institution - 551
🇸🇪Stockholm, Sweden
Local Institution - 450
🇨🇭Bern, Switzerland
Local Institution - 452
🇨🇭Luzern 16, Switzerland
Local Institution - 451
🇨🇭Winterthur, Switzerland
Local Institution - 220
🇨🇳Changhua City, Changhua, Taiwan
Local Institution - 222
🇨🇳Niaosong District Kaohsiung City, Taiwan
Local Institution - 223
🇨🇳Taichung City, Taiwan
Local Institution - 224
🇨🇳Taichung, Taiwan
Local Institution - 221
🇨🇳Taipei, Taiwan
Local Institution - 342
🇹🇷Ankara, Turkey
Local Institution - 340
🇹🇷Manisa, Turkey
Local Institution - 343
🇹🇷Trabzon, Turkey
Local Institution - 526
🇺🇦Cherkassy, Ukraine
Local Institution - 525
🇺🇦Dnipro, Ukraine
Local Institution - 522
🇺🇦Kyiv, Ukraine
Local Institution - 520
🇺🇦Lvov, Ukraine
Local Institution - 523
🇺🇦Mykolaiv, Ukraine
Local Institution - 521
🇺🇦Ternopil, Ukraine
Local Institution - 401
🇬🇧Aberdeen, United Kingdom
Local Institution - 403
🇬🇧Bournemouth, United Kingdom
Local Institution - 405
🇬🇧Headington, Oxford, United Kingdom
Local Institution - 407
🇬🇧Lincoln, United Kingdom
Local Institution - 404
🇬🇧London, United Kingdom
Local Institution - 400
🇬🇧Manchester, United Kingdom