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Coney JM, McCoy JE, Buxy Sinha S, Sonbolian N, Zhou L, Hull TP, Lewis SA, Miller DG, Novak MA, Pendergast SD, Pham H, Platt SM, Rao LJ, Schartman JP, Singerman LJ, Donkor R, Fink M, Zubricky R, Karcher H. One-Year and 18-Month Outcomes in nAMD Patient Eyes Switched to Brolucizumab Alone versus to Brolucizumab Alternating with Other Anti-VEGF Agents. Clin Ophthalmol 2023; 17:3601-3611. [PMID: 38026599 PMCID: PMC10680460 DOI: 10.2147/opth.s432957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Retrospective, real-world study to evaluate visual acuity (VA), anti-vascular endothelial growth factor (anti-VEGF) injection intervals, and central macular thickness (CMT) in neovascular age-related macular degeneration (nAMD) eyes switched to brolucizumab only or to brolucizumab alternating with another anti-VEGF. Methods The overall study population comprised eyes that were given ≥1 brolucizumab injection between 1 October 2019 and 30 November 2021. The brolucizumab-only (BRO) cohort consisted of prior anti-VEGF-treated eyes treated exclusively with ≥3 brolucizumab injections over ≥12 or ≥18 months; the alternating brolucizumab (ALT) cohort comprised prior anti-VEGF-treated eyes treated with ≥2 brolucizumab injections and ≥1 other anti-VEGF over ≥12 or ≥18 months. Results A total of 482 eyes received ≥1 brolucizumab injection during the study period. Mean VA changes from baseline were -1.1±15.1 letters (BRO cohort; n = 174) and 1.3±13.0 letters (ALT cohort; n = 47) at Month 12, and 0.0±13.5 letters (BRO cohort; n = 95) and -7.3±17.2 letters (ALT cohort; n = 29) at Month 18. Mean changes in injection intervals were +26.9±48.1 days (BRO cohort) and +11.1±17.3 days (ALT cohort) at Month 12 and +36.3±52.3 days (BRO cohort) and +14.0±19.9 days (ALT cohort) at Month 18. Mean changes in CMT were -35.2±108.1 μm (BRO cohort) and -31.5±91.2 μm (ALT cohort) at Month 12 and -38.9±75.0 μm (BRO cohort) and -9.0±59.9 μm (ALT cohort) at Month 18. Intraocular inflammation-related adverse events were recorded in 22/482 (4.6%) eyes. Conclusion Treatment with either brolucizumab alone or brolucizumab alternating with another anti-VEGF can preserve vision, reduce CMT, and extend anti-VEGF injection intervals in patients with nAMD.
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Affiliation(s)
| | | | | | | | | | - Thomas P Hull
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | - Shawn A Lewis
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | | | | | | | - Hang Pham
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | - Sean M Platt
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
| | | | | | | | | | - Margaret Fink
- Retina Associates of Cleveland Inc, Beachwood, OH, USA
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Abdulaal M, Donkor R, Robertson J, Lewis S, Miller DG, Schartman J, Platt S, Coney JM. Early surgical displacement of submacular hemorrhage without tissue plasminogen activator use: one-year outcomes. Can J Ophthalmol 2023:S0008-4182(23)00310-1. [PMID: 37925165 DOI: 10.1016/j.jcjo.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/15/2023] [Accepted: 10/04/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE This study evaluated changes in best-corrected visual acuity and submacular hemorrhage (SMH) resolution in eyes after a single rapid subretinal displacement surgery using subretinal balanced saline solution and sterile air without tissue plasminogen activator (tPA). DESIGN A retrospective comparative interventional analysis. PARTICIPANTS Twenty-six eyes with thick SMH who underwent pars plana vitrectomy and subretinal fluid displacement without tPA from 2015 and 2021 and at least 1-year of follow-up. METHODS Surgical intervention included a standard small-gauge pars plana vitrectomy with subretinal displacement using balanced saline solution with subretinal sterile air and partial gas-air fluid exchange. Main outcome measures included degree of subfoveal SMH displacement, best and final postoperative visual acuities, and adverse events. Snellen acuity was converted to logMARs for statistical analysis. RESULTS The most common etiology associated with thick SMH (92.3%) was neovascular age-related macular degeneration. Within 1 month postoperatively, 21 patients (80.8%) saw complete subfoveal blood displacement. Most of the SMH surgical displacements were done within 1 week of presenting symptoms. Average preoperative duration of SMH was 3.60 ± 2.78 days (range, 1-12 days). Mean logMAR best-corrected visual acuity improved from 1.63 ± 0.58 (Snellen 20/800 baseline) to 0.90 ± 0.42 letters (Snellen 20/160) at last follow-up (p = 0.001). This study's visual acuity improvement is comparable with that of prior studies using tPA. Early postoperative complications included 1 retinal detachment, 1 vitreous hemorrhage, and 1 macular hole. CONCLUSION Rapid surgery with subretinal balanced saline solution-sterile air injection without tPA was found to be effective for displacement of thick SMH with retinal function, visual acuity, and corneal refractive therapy improvement.
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Affiliation(s)
| | | | | | - Shawn Lewis
- Retina Associates of Cleveland, Beachwood, OH
| | | | | | - Sean Platt
- Retina Associates of Cleveland, Beachwood, OH
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Miller DG, Yegya-Raman N, Friedes C, Cengel KA, Plastaras JP, Simone Ii CB, Cohen R, Langer C, Feigenberg SJ, Butala AA. Pneumonitis after Palliative Thoracic Radiotherapy +/- Immunotherapy: A Retrospective Propensity-Matched Cohort Study. Int J Radiat Oncol Biol Phys 2023; 117:e138. [PMID: 37784706 DOI: 10.1016/j.ijrobp.2023.06.945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Patients (pts) with advanced lung cancer often receive combined palliative thoracic radiotherapy (RT) and immune checkpoint inhibitors (ICI). There are limited data assessing the toxicities of combined ICI-RT in this setting. We sought to compare the rates of clinically significant pneumonitis among pts with lung cancer receiving palliative thoracic RT with or without recent or concomitant ICI. We hypothesized there would be a higher rate of grade 2+ pneumonitis among RT pts who received recent or concomitant ICI compared to those who did not. MATERIALS/METHODS We retrospectively identified consecutive pts with advanced/recurrent lung cancer from a tertiary academic center who received palliative thoracic RT with recent (defined as within 95 days of RT start) or concomitant ICI (ICI-RT group) between January 2014 and February 2020. Pts were propensity matched in a 1:1 manner (by age, sex, ECOG, RT modality, and RT dose) to lung cancer pts who received palliative thoracic RT without any history of ICI receipt (RT-only group). The presence and grade (CTCAE v5.0) of pneumonitis were independently assessed by two investigators. The primary endpoint was grade 2+ pneumonitis, estimated using the cumulative incidence function and compared between the ICI-RT and RT-only groups using Gray's test. The secondary endpoint was overall survival, estimated using the Kaplan-Meier method and compared between groups using the log-rank test. RESULTS A total of 146 pts were included in the study (73 in each group). There were no statistically significant differences between the ICI-RT and RT-only groups with respect to age (median 67.7 vs. 67.6, p = 0.97), sex (52% vs. 52% female, p = 1.00), pre-treatment ECOG 0-1 (74% vs 75%, p = 0.85), or biologically effective dose greater than 45 (48% vs. 48%, p = 1.00). The most common RT regimens were 30 Gy in 10 fractions (33 pts, 23%) and 20 Gy in 5 fractions (18 patients, 12%). A plurality of cases utilized 3DCRT (67 pts, 46%). In the ICI-RT group, the median time from last dose of ICI to the start of palliative RT was 16 days; three pts in this group-initiated ICI while receiving RT treatment. The most common ICI was pembrolizumab (36 pts, 49%). A total of eleven grade 2+ pneumonitis events (nine grade 2 and two grade 3 events) were observed. The ICI-RT group had a higher cumulative incidence of grade 2+ pneumonitis compared with the RT-only group (1-year rate, 12.3% vs. 2.7%, p = 0.029); grade 3 pneumonitis occurred in 1/73 (1.4%) in each group. There was no difference in overall survival between groups (median 239 vs. 218 days, p = 0.76). CONCLUSION In pts with advanced lung cancer treated with palliative thoracic RT, recent or concomitant ICI use was associated with a higher cumulative incidence of grade 2+ pneumonitis. However, the incidence of grade 3+ pneumonitis was low (1.4%) regardless of ICI receipt.
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Affiliation(s)
- D G Miller
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - N Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - C Friedes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - K A Cengel
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - J P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | | | - R Cohen
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - C Langer
- Department of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA
| | - S J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - A A Butala
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Zubricky R, McCoy J, Donkor R, Miller DG, Sonbolian N, Heaney A, Bilano V, Karcher H, Coney JM. Real-World Frequency and Management of Ocular Adverse Events in Eyes with Neovascular Age-Related Macular Degeneration Treated with Brolucizumab. Ophthalmol Ther 2023; 12:2397-2408. [PMID: 37310683 PMCID: PMC10442012 DOI: 10.1007/s40123-023-00741-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/17/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Intraocular inflammation (IOI)-related adverse events (AEs) that may result in severe vision loss have been associated with the anti-vascular endothelial growth factor brolucizumab. In this study, we investigate the timing, management and resolution of IOI-related AEs in a large cohort of patients treated with at least one injection of brolucizumab in routine clinical practice. METHODS Retrospective review of medical records from patients with neovascular age-related macular degeneration treated with ≥ 1 brolucizumab injection between October 2019 and November 2021 at the Retina Associates of Cleveland, Inc. clinics. RESULTS Of the 482 eyes included in the study, IOI-related AEs occurred in 22 (4.6%) eyes. Four (0.8%) eyes developed retinal vasculitis (RV) and of these, 2 (0.4%) had concomitant retinal vascular occlusion (RO). Most eyes [14/22 (64%)] developed the AE within 3 months and 4/22 (18%) within 3-6 months of the first brolucizumab injection. The median [interquartile range (IQR)] time from the last brolucizumab injection to development of the IOI-related AE was 13 (4-34) days. At the time of event, 3 (0.6%) eyes with IOI (no RV/RO) developed severe vision loss of ≥ 30 ETDRS letters, and a further 5 (1.0%) eyes (1 with IOI + RV, 1 with IOI + RV + RO) developed moderate vision loss of ≥ 15 letters compared with their last visual acuity (VA) prior to the AE. The median (IQR) vision loss was -6.8 (-19.9, -0.0) letters. Taking the best VA at either 3 or 6 months after AE resolution (or stability for occlusive events), VA decreased by ≥ 5 letters compared with prior to the AE in 3 (14%) of the 22 affected eyes, and was preserved (< 5-letter loss) in 18 (82%) eyes. CONCLUSIONS In this real-world study, most IOI-related AEs occurred early after brolucizumab treatment initiation. With appropriate monitoring and management of IOI-related AEs, vision loss associated with brolucizumab may be limited.
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Affiliation(s)
| | - Jasmyne McCoy
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH, 44122, USA
| | - Richard Donkor
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH, 44122, USA
| | - David G Miller
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH, 44122, USA
| | | | | | | | | | - Joseph M Coney
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH, 44122, USA.
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Coney JM, Zubricky R, Sinha SB, Sonbolian N, Zhou L, Hull TP, Lewis SA, Miller DG, Novak MA, Pendergast SD, Pham H, Platt SM, Rao LJ, Schartman JP, Singerman LJ, Donkor R, Fink M, McCoy J, Karcher H. Switching to brolucizumab: injection intervals and visual, anatomical and safety outcomes at 12 and 18 months in real-world eyes with neovascular age-related macular degeneration. Int J Retina Vitreous 2023; 9:8. [PMID: 36726178 PMCID: PMC9891747 DOI: 10.1186/s40942-023-00445-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The anti-vascular endothelial growth factor (anti-VEGF) injection interval influences treatment burden and compliance in neovascular age-related macular degeneration (nAMD). This real-world study investigates visual acuity (VA), injection-interval extension, central macular thickness (CMT) and safety in nAMD eyes switched to the anti-VEGF agent brolucizumab and followed for up to 18 months. METHODS This retrospective study included patients with nAMD who were switched from other anti-VEGF agents to brolucizumab only. Patient eyes were grouped into three nested cohorts with the overall cohort receiving ≥ 1 brolucizumab injection, the second receiving ≥ 3 brolucizumab injections with a follow-up period of ≥ 12 months and the third cohort receiving ≥ 3 brolucizumab injections with a follow-up period of ≥ 18 months. Study endpoints included changes from baseline at 12 or 18 months in VA, injection intervals, and CMT. Sub-group analyses were conducted using baseline injection interval length or baseline VA as qualifiers. RESULTS Overall, 482 eyes received ≥ 1 brolucizumab injection; 174 eyes received ≥ 3 brolucizumab injections with ≥ 12 months of follow-up, and 95 eyes received ≥ 3 brolucizumab injections with ≥ 18 months of follow-up. VA (mean [95% confidence intervals]) remained stable relative to baseline after 12 months (- 1.1 [- 3.7, 1.6] letters; p = 0.42) and 18 months (0.0 [- 3.1, 3.1] letters; p = 0.98) of brolucizumab treatment, respectively, and pre-switch injection intervals or baseline VA had no notable effect. Following the switch to brolucizumab, injection intervals were extended from baseline to month 12 by 26.9 (19.7, 34.0) days (p < 0.0001), and eyes with pre-switch injection intervals < 8 weeks were able to have their injection intervals extended by 23.6 days longer than eyes with pre-switch injection intervals ≥ 8 weeks. At 18 months, injection intervals were extended by 36.3 (25.6, 46.9) days (p < 0.0001) compared to baseline. Following switch to brolucizumab, CMT was reduced at both 12 and 18 months (12 months: - 35.2 (- 51.7, - 18.8) µm, p < 0.0001; 18 months: - 38.9 (- 54.3, - 22.0) µm, p < 0.0001). Intraocular inflammation-related adverse events were reported in 4.6% of brolucizumab-treated eyes. CONCLUSIONS This real-world study demonstrates that injection intervals may be significantly extended with maintained vision and reduced CMT in nAMD eyes switching to brolucizumab therapy from other anti-VEGFs.
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Affiliation(s)
- Joseph M. Coney
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | | | | | - Nina Sonbolian
- grid.419481.10000 0001 1515 9979Novartis AG, Basel, Switzerland
| | | | - Thomas P. Hull
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Shawn A. Lewis
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - David G. Miller
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Michael A. Novak
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Scott D. Pendergast
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Hang Pham
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Sean M. Platt
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Llewelyn J. Rao
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Jerome P. Schartman
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | | | - Richard Donkor
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Margaret Fink
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Jasmyne McCoy
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Beachwood, OH 44122 USA
| | - Helene Karcher
- grid.419481.10000 0001 1515 9979Novartis AG, Basel, Switzerland
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Miller CW, Wilneff MA, Wuller AL, Platt SM, Schartman JP, Lewis SA, Rao LJ, Wuller SL, Miller DG. Frequency and Symptoms of Intravitreal Silicone Oil Droplets Following Becton Dickinson and Norm-Ject Bevacizumab Injections. Ophthalmic Surg Lasers Imaging Retina 2022; 53:108-112. [PMID: 35148214 DOI: 10.3928/23258160-20220124-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine silicone oil droplet frequency and symptomatic impact in patients injected with Norm-Ject (NJ) and/or Becton Dickinson (BD) intravitreal bevacizumab. PATIENTS AND METHODS This was a retrospective cohort study of 426 patients with prior bevacizumab injection(s). Symptomatic floaters questionnaire responses were compiled and statistical analysis was performed using Fisher's exact t test with 95% CI calculated via the modified Wald method. RESULTS Patients who received BD intravitreal bevacizumab showed more droplets (67.2%) than those who received NJ intravitreal bevacizumab (7.8%), and droplets increased with injection quantity. However, the symptomatic patients reporting new floaters were similar (NJ: 39.22%, BD: 39.47%). [Ophthalmic Surg Lasers Imaging Retina. 2022;53:108-112.].
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Miller A, Wilneff MA, Yazji A, Petrinec E, Carbone M, Miller C, McCrossin C, Donkor R, Miller DG. Analysis of urgent follow up visits and complications after intravitreal injections: a retrospective cohort study. Int J Retina Vitreous 2022; 8:8. [PMID: 35042547 PMCID: PMC8764861 DOI: 10.1186/s40942-021-00358-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/28/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intravitreal injections (IVIs), a common treatment in ophthalmology, result in acute complications and urgent follow-up visits causing significant burden to both patient and physician. We evaluated the incidence of acute complications following IVIs which occurred within seven days of injection. METHODS A retrospective cohort study conducted at a private retinal practice, in Cleveland, Ohio. Using the practice management software database, we examined 73,286 injections of patients with unscheduled or urgent visits within 7 days of an injection from August 1st,2018 to August 1st,2020. Data collected included: age, gender, eye, medication injected, diagnosis, reason for urgent follow-up, time between injection and urgent follow-up, and type of anesthesia administered. Data was analyzed using SPSS v.28 (SPSS Inc., Chicago IL). RESULTS Study included 73,286 injections, with 441 injections (n = 441) resulting in urgent follow-up visits (0.60%). Mean patient age was 72.1 (± 30.4) years, with 187 male (42.4%) and 254 female (57.6%) patients. IVI medications included: aflibercept (60.3%), ranibizumab (22.4%), bevacizumab (13.4%), dexamethasone intravitreal implant (2%), triamcinolone acetonide (1.6%) brolucizumab (1.59%), fluocinolone acetonide intravitreal implant 0.19 mg (0.2%), and fluocinolone acetonide intravitreal implant 0.18 mg (0.03%) (Table 1). Medications associated with urgent visits included: aflibercept (42.9%), bevacizumab (37.4%), ranibizumab (7.9%), dexamethasone intravitreal implant (6.8%), brolucizumab (2.7%), and triamcinolone acetonide (2.3%) (Table 2). Days between injection and urgent follow-up was on average 3.96 ± 2.14 days. Urgent follow-ups included blurred vision in 164 patients (37.2% of urgent visits), flashes, floaters or posterior vitreous detachment (PVD) in 55 (12.5%), pain in 42 (9.5%), 43 (9.8%) corneal abrasions, 33 (7.5%) subconjunctival hemorrhages, corneal dryness or foreign body sensation in 30 (6.6%), endophthalmitis in 20 (4.5%), 18 (4.1%)vitreous hemorrhages, iritis or uveitis in 11 (2.5%), miscellaneous complications in 9 (2.0%), 7 (1.6%) elevated intraocular pressures, choroidal neovascular membrane in 4 (0.9%), 4 (0.9%) retinal detachments or tears, and 2 (0.45%) traumatic cataracts (Table 3). CONCLUSION IVIs resulted in 0.60% urgent/unscheduled follow-up visits within 7 days of injection. Most common causes were blurred vision and symptoms of PVD.
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Affiliation(s)
- Alexander Miller
- Northeastern Ohio Medical University, Rootstown, OH, USA
- University Hospital - Mason Eye Clinic, Columbia, MO, USA
| | - Matthew A Wilneff
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
| | - Andrew Yazji
- Northeastern Ohio Medical University, Rootstown, OH, USA
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Cleveland, OH, USA
| | - Emily Petrinec
- Northeastern Ohio Medical University, Rootstown, OH, USA
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Cleveland, OH, USA
| | - Michael Carbone
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Cleveland, OH, USA
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Chase Miller
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Cleveland, OH, USA
| | | | - Richard Donkor
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Cleveland, OH, USA
| | - David G Miller
- Retina Associates of Cleveland Inc, 24075 Commerce Park, Cleveland, OH, USA.
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Miller AG, Chandra R, Pophal C, Schartman JP, Hornik JH, Miller DG. Efficacy of Macular Hole Surgery in Patients with Idiopathic Macular Telangiectasia Type 2. Ophthalmol Retina 2019; 4:494-497. [PMID: 32063517 DOI: 10.1016/j.oret.2019.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/07/2019] [Accepted: 11/22/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare visual acuity (VA) and OCT outcomes in patients with idiopathic macular telangiectasia (IMT) type 2 who underwent pars plana vitrectomy (PPV) surgery for full-thickness macular holes (FTMHs) versus those who elected to be medically managed (MM) without surgery. DESIGN Comparative retrospective case series. PARTICIPANTS Patients with IMT type 2 and FTMH. METHODS We reviewed records within an 11-year period and collected data on VA, OCT changes, development of choroidal neovascularization, and length of follow-up. The VA measurements were standardized from Snellen to logarithm of the minimum angle of resolution units for statistical analysis. Two-sample t tests were used to analyze VA data. OCT changes were assessed by a single masked retinal specialist. RESULTS There were 12 eyes in the PPV group and 26 eyes in the MM group. There was no statistically significant VA improvement in either group between initial VA recording and last follow-up. The PPV group had no significant change in VA between the preoperative visit and the visits at 3 or 12 months. OCT scans improved by 1 step in 10 patients in the PPV group. None of the patients in the MM group had OCT improvement. Choroidal neovascularization developed in 1 eye in the PPV group and 5 eyes in the MM group. CONCLUSIONS There was no significant change in VA in patients who opted to have PPV to treat their IMT type 2 and FTMH compared with those who did not undergo surgery. OCT scans improved by qualitative judgment in patients who underwent surgery compared with those who opted for medical management.
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Affiliation(s)
- Alexander G Miller
- Retina Associates of Cleveland, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Rohit Chandra
- Retina Associates of Cleveland, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | - Charles Pophal
- Retina Associates of Cleveland, Cleveland, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
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Ge J, Polhill JG, Matthews KB, Miller DG, Spencer M. Not one Brexit: How local context and social processes influence policy analysis. PLoS One 2018; 13:e0208451. [PMID: 30557363 PMCID: PMC6296738 DOI: 10.1371/journal.pone.0208451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 11/16/2018] [Indexed: 11/19/2022] Open
Abstract
This paper develops an empirical agent-based model to assess the impacts of Brexit on Scottish cattle farms. We first identify several trends and processes among Scottish cattle farms that were ongoing before Brexit: the lack of succession, the rise of leisure farming, the trend to diversify and industrialise, and, finally, the phenomenon of the "disappearing middle", characterised by the decline of medium-sized farms and the polarization of farm sizes. We then study the potential impact of Brexit amid the local context and those ongoing social processes. We find that the impact of Brexit is indeed subject to pre-Brexit conditions. For example, whether industrialization is present locally can significantly alter the impact of Brexit. The impact of Brexit also varies by location: we find a clear divide between constituencies in the north (highland and islands), the middle (the central belt) and the south. Finally, we argue that policy analysis of Brexit should consider the heterogeneous social context and the complex social processes under which Brexit occurs. Rather than fitting the world into simple system models and ignoring the evidence when it does not fit, we need to develop policy analysis frameworks that can incorporate real world complexities, so that we can assess the impacts of major events and policy changes in a more meaningful way.
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Affiliation(s)
- Jiaqi Ge
- The James Hutton Institute, Aberdeen, United Kingdom
- * E-mail:
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Sciulli H, Miller CW, Rao LJ, Hornik JH, Rowland DY, Miller DG. Retinal Surgery in Ambulatory Surgery Centers versus Hospital Outpatient Departments. Ophthalmol Retina 2017; 1:563-564. [PMID: 31047457 DOI: 10.1016/j.oret.2017.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/19/2017] [Accepted: 01/20/2017] [Indexed: 06/09/2023]
Affiliation(s)
- Harrison Sciulli
- Retina Associates of Cleveland, Cleveland, Ohio; University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | | | | | - Douglas Y Rowland
- DY Rowland Associates, Cleveland Heights, Ohio; Department of Epidemiology & Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Holfinger S, Miller AG, Rao LJ, Rowland DY, Hornik JH, Miller DG. Effect of Regulatory Requirement for Patient-Specific Prescriptions for Off-Label Medications on the Use of Intravitreal Bevacizumab. JAMA Ophthalmol 2015; 134:45-8. [PMID: 26540671 DOI: 10.1001/jamaophthalmol.2015.4331] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Requirements regulating pharmaceutical prescriptions can affect physicians' choice of therapy in a clinical setting. OBJECTIVE To evaluate the change in bevacizumab use after the regulatory requirement for patient-specific prescriptions (PSPs) for off-label medications in Ohio. DESIGN, SETTING, AND PARTICIPANTS This study retrospectively reviewed the aggregate data from the billing records of patients receiving 1.25-mg injections of bevacizumab, 0.3- or 0.5-mg injections of ranibizumab, or 2.0-mg injections of aflibercept for age-related macular degeneration or diabetic macular edema in a 9-member retinal specialty private practice. The review assessed 4488 intravitreal injections in the 3-month period before (May 1 to July 30, 2012) and 5253 injections in the 3-month period after (May 1 to July 30, 2013) the Ohio Board of Pharmacy's requirement of PSPs for bevacizumab. Relative proportions of the drugs used for intravitreal injections were calculated and frequencies were compared. A Likert scale survey was conducted among the 9 physicians to identify reasons for their change in prescription of bevacizumab. The survey inquired about (1) the burden of PSPs, (2) concern about differences in efficacy, and (3) concern about differences in safety. MAIN OUTCOMES AND MEASURES Difference in drug use before and after the PSP requirement for bevacizumab and the physicians' reasons for change in their drug use. RESULTS Bevacizumab use decreased from 2752 of 4488 pre-PSP injections (61.3%) to 1503 of 5253 post-PSP injections (28.6%), a change of -32.7% (95% CI, -34.6% to -30.8%; P < .001). Use of 0.5-mg ranibizumab injections increased from 1122 of 4488 pre-PSP injections (25.0%) to 1838 of 5253 post-PSP injections (35.0%), a change of 10.0% (95% CI, 8.2% to 11.8%; P < .001). Use of 0.3-mg ranibizumab injections increased from 0 of 4488 (before US Food and Drug Administration approval) to 429 of 5253 post-PSP injections (8.2%), a change of 8.2% (95% CI, 7.4% to 8.9%; P < .001). Use of aflibercept injections increased from 614 of 4488 pre-PSP injections (13.7%) to 1483 of 5253 post-PSP injections (28.2%), a change of 14.6% (95% CI, 13.0%-16.1%; P < .001). In the survey of the 9 physicians concerning their reasons for decreased use of bevacizumab, 7 (78%) strongly agreed and 1 (11%) agreed that the burden of PSPs changed their choice of drug used for injection. CONCLUSIONS AND RELEVANCE Use of bevacizumab was reduced by 32.7% 1 year after the regulatory requirement for PSPs for compounded (repackaged) medications. This change seemed to have more association with the requirement for PSPs than with a known change in efficacy or safety concerns. Although this study was based on a single US practice, regulation of repackaged medication for safety concerns should also consider the evaluation of treatment burden, cost, and adherence.
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Affiliation(s)
| | | | | | - Douglas Y Rowland
- DY Rowland Associates, Cleveland Heights, Ohio4Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Miller DG. International Academy of Compounding Pharmacists' Legislative Regulatory Update: Take Action! Stop the U.S. Food and Drug Administration's Misguided Veterinary Guidance. Int J Pharm Compd 2015; 19:449-450. [PMID: 26891558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Miller DG. The International Academy of Compounding Pharmacists Comments to the Draft Memorandum of Understanding ADDRESSING CERTAIN DISTRIBUTIONS OF COMPOUNDED HUMAN DRUG PRODUCTS BETWEEN THE STATE AND THE U.S. FOOD AND DRUG ADMINISTRATION. Int J Pharm Compd 2015; 19:375. [PMID: 26775443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Miller DG. U.S. FOOD AND DRUG ADMINISTRATION PROPOSED GUIDANCE DOCUMENT: Compounding Animal Drugs from Bulk Substances. Int J Pharm Compd 2015; 19:303-305. [PMID: 26625566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Winawer SJ, Miller DG, Schottenfeld D, Befler B, Bhargava D, Leidner SD, Sherlock P, Dressler M, Kurtz RC, Stearns M. Screening for colorectal cancer with fecal occult blood testing. Front Gastrointest Res 2015; 5:28-34. [PMID: 499991 DOI: 10.1159/000402309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Miller DG. Standing Together Fixing the Drug Quality and Security Act. Int J Pharm Compd 2015; 19:104-106. [PMID: 26685490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Miller DG. Compounding legislation: focus shifts to states. Int J Pharm Compd 2014; 18:470-472. [PMID: 25906623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Miller DG. IACP's continuing support of compounding pharmacists: letter to the FDA concerning 503B outsourcing facilities. Int J Pharm Compd 2014; 18:117-118. [PMID: 24881114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Miller DG. U.S. Food and Drug Administration requests for input on HR 3204 enactment: the Drug Quality and Security Act of 2013. Int J Pharm Compd 2014; 18:35-36. [PMID: 24881338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Bressler SB, Qin H, Melia M, Bressler NM, Beck RW, Chan CK, Grover S, Miller DG. Exploratory analysis of the effect of intravitreal ranibizumab or triamcinolone on worsening of diabetic retinopathy in a randomized clinical trial. JAMA Ophthalmol 2013; 131:1033-40. [PMID: 23807371 DOI: 10.1001/jamaophthalmol.2013.4154] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The standard care for proliferative diabetic retinopathy (PDR) usually is panretinal photocoagulation, an inherently destructive treatment that can cause iatrogenic vision loss. Therefore, evaluating the effects of therapies for diabetic macular edema on development or worsening of PDR might lead to new therapies for PDR. OBJECTIVE To evaluate the effects of intravitreal ranibizumab or triamcinolone acetonide, administered to treat diabetic macular edema, on worsening of diabetic retinopathy. DESIGN Exploratory analysis was performed on worsening of retinopathy, defined as 1 or more of the following: (1) worsening from no PDR to PDR, (2) worsening of 2 or more severity levels on reading center assessment of fundus photographs in eyes without PDR at baseline, (3) having panretinal photocoagulation, (4) experiencing vitreous hemorrhage, or (5) undergoing vitrectomy for the treatment of PDR. SETTING Community- and university-based ophthalmology practices. PARTICIPANTS Individuals with central-involved diabetic macular edema causing visual acuity impairment. INTERVENTIONS Eyes were assigned randomly to sham with prompt focal/grid laser, 0.5 mg of intravitreal ranibizumab with prompt or deferred (≥24 weeks) laser, or 4 mg of intravitreal triamcinolone acetonide with prompt laser. MAIN OUTCOMES AND MEASURES Three-year cumulative probabilities for retinopathy worsening. RESULTS For eyes without PDR at baseline, the 3-year cumulative probabilities for retinopathy worsening (P value comparison with sham with prompt laser) were 23% using sham with prompt laser, 18% with ranibizumab with prompt laser (P = .25), 7% with ranibizumab with deferred laser (P = .001), and 37% with triamcinolone with prompt laser (P = .10). For eyes with PDR at baseline, the 3-year cumulative probabilities for retinopathy worsening were 40%, 21% (P = .05), 18% (P = .02), and 12% (P < .001), respectively. CONCLUSIONS AND RELEVANCE Intravitreal ranibizumab appears to be associated with a reduced risk of diabetic retinopathy worsening in eyes with or without PDR. Intravitreal triamcinolone also appears to be associated with a reduced risk of PDR worsening. These findings suggest that use of these drugs to prevent worsening of diabetic retinopathy may be feasible. Given the exploratory nature of these analyses, the risk of endophthalmitis following intravitreal injections, and the fact that intravitreal triamcinolone can cause cataract or glaucoma, use of these treatments to reduce the rates of worsening of retinopathy, with or without PDR, does not seem warranted at this time.
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Affiliation(s)
- Susan B Bressler
- Retina Division, Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Miller DG. 2013 State Compounding Legislation Tracker. Int J Pharm Compd 2013; 17:375-378. [PMID: 24459782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Miller DG. International Academy of Compounding Pharmacists. Legislative/regulatory update. Preserving patient access--compounders on Capitol Hill 2013! Int J Pharm Compd 2013; 17:302-304. [PMID: 24261145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA
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Miller DG. International Academy of Compounding Pharmacists' legislative/regulatory update. Int J Pharm Compd 2013; 17:206. [PMID: 24046936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA
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Miller DG. International Academy of Compounding Pharmacists' recommendations for state-based legislative and regulatory initiatives. Int J Pharm Compd 2013; 17:48-49. [PMID: 23627246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA.
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Miller DG. Legislative/regulatory update from the International Academy of Compounding Pharmacists. Int J Pharm Compd 2012; 16:476-478. [PMID: 23259363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA
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Miller DG. Legislative/Regulatory Update from the International Academy of Compounding Pharmacists. Int J Pharm Compd 2012; 16:300-302. [PMID: 23050389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA
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van Rensburg R, Beyer I, Yao XY, Wang H, Denisenko O, Li ZY, Russell DW, Miller DG, Gregory P, Holmes M, Bomsztyk K, Lieber A. Chromatin structure of two genomic sites for targeted transgene integration in induced pluripotent stem cells and hematopoietic stem cells. Gene Ther 2012; 20:201-14. [PMID: 22436965 PMCID: PMC3661409 DOI: 10.1038/gt.2012.25] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Achieving transgene integration into preselected genomic sites is currently one of the central tasks in stem cell gene therapy. A strategy to mediate such targeted integration involves site specific endonucleases. Two genomic sites within the MBS85 and CCR5 genes [AAVS1 and CCR5 zinc finger nuclease (CCR5-ZFN) site, respectively] have recently been suggested as potential target regions for integration as their disruption has no functional consequence. We hypothesized that efficient transgene integration maybe affected by DNA accessibility of endonucleases and therefore studied the transcriptional and chromatin status of the AAVS1 and CCR5 sites in eight human induced pluripotent stem (iPS) cell lines and pooled CD34+ hematopoietic stem cells. Matrixchromatin immunoprecipitation (ChIP) assays demonstrated that the CCR5 site and surrounding regions possessed a predominantly closed chromatin configuration consistent with its transcriptionally inactivity in these cell types. In contrast, the AAVS1 site was located within a transcriptionally active region and exhibited an open chromatin configuration in both iPS cells and hematopoietic stem cells. To show that the AAVS1 site is readily amendable to genome modification, we expressed Rep78, an AAV2-derived protein with AAVS1-specific endonuclease activity, in iPS cells after adenoviral gene transfer. We showed that Rep78 efficiently associated with the AAVS1 site and triggered genome modifications within this site. On the other hand, binding to and modification of the CCR5-ZFN site by a zinc-finger nuclease was relatively inefficient. Our data suggest a critical influence of chromatin structure on efficacy of site-specific endonucleases used for genome editing.
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Affiliation(s)
- R van Rensburg
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA
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Miller DG. The International Academy of Compounding Pharmacists stepping up efforts to remedy problems caused by the U.S. Drug Enforcement Administration's "constructive transfer" policy. Int J Pharm Compd 2012; 16:94-96. [PMID: 23050319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA
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Miller DG. Legislative/regulatory update from the International Academy of Compounding Pharmacists. Int J Pharm Compd 2012; 16:50-52. [PMID: 23050311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- David G Miller
- International Academy of Compounding Pharmacists, Washington, DC, USA
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Wells HS, Youmans JB, Miller DG. TISSUE PRESSURE (INTRACUTANEOUS, SUBCUTANEOUS, AND INTRAMUSCULAR) AS RELATED TO VENOUS PRESSURE, CAPILLARY FILTRATION, AND OTHER FACTORS. J Clin Invest 2006; 17:489-99. [PMID: 16694596 PMCID: PMC434805 DOI: 10.1172/jci100976] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- H S Wells
- Department of Physiology, Vanderbilt University School of Medicine, Nashville
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Affiliation(s)
- H S Wells
- Laboratory of Physiology, Vanderbilt University School of Medicine, Nashville
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Wells HS, Youmans JB, Miller DG. A FORMULA AND NOMOGRAM FOR THE ESTIMATION OF THE OSMOTIC PRESSURE OF COLLOIDS FROM THE ALBUMIN AND TOTAL PROTEIN CONCENTRATIONS OF HUMAN BLOOD SERA. J Clin Invest 2006; 12:1103-17. [PMID: 16694185 PMCID: PMC435967 DOI: 10.1172/jci100561] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- H S Wells
- Department of Physiology, Vanderbilt University Medical School, Nashville
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Youmans JB, Wells HS, Donley D, Miller DG, Frank H. THE EFFECT OF POSTURE (STANDING) ON THE SERUM PROTEIN CONCENTRATION AND COLLOID OSMOTIC PRESSURE OF BLOOD FROM THE FOOT IN RELATION TO THE FORMATION OF EDEMA. J Clin Invest 2006; 13:447-59. [PMID: 16694221 PMCID: PMC436005 DOI: 10.1172/jci100597] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- J B Youmans
- Department of Medicine, Vanderbilt University School of Medicine, Nashville
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Abstract
Choroidal neovascularization (CNV) is a common cause of vision loss in patients <50 years of age. In these patients, CNV is often the result of pathologic myopia, ocular histoplasmosis syndrome, angioid streaks, or idiopathic causes. Rarely, CNV is seen in children, usually in association with inherited macular dystrophies such as Best's disease (vitelliform macular dystrophy) or drusen of the optic nerve. This article discusses the role of optometrists in the detection and management of CNV. Untreated CNV can cause rapid deterioration of central vision and is associated with a poor prognosis. Optometrists may be able to improve the prognosis of younger patients with CNV by recognizing the signs, symptoms, and risk factors for CNV and promptly referring patients with suspected CNV to a retina specialist. They can also help patients by providing long-term support and rehabilitation. Recent treatment advances, such as the availability of verteporfin (Visudyne; Novartis Pharma AG, Basel, Switzerland) therapy, that are applicable to younger patients with CNV have increased the importance of early detection of CNV and prompt referral of patients to a specialist who can treat CNV.
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Affiliation(s)
- David G Miller
- Retina Associates of Cleveland, Inc., Cleveland, Ohio 44122, USA.
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Abstract
We used mitochondrial DNA data to infer phylogenies for 28 samples of gall-inducing Tamalia aphids from 12 host-plant species, and for 17 samples of Tamalia inquilinus, aphid 'inquilines' that obligately inhabit galls of the gall inducers and do not form their own galls. Our phylogenetic analyses indicate that the inquilines are monophyletic and closely related to their host aphids. Tamalia coweni aphids from different host plants were, with one exception, very closely related to one another. By contrast, the T. inquilinus aphids were strongly genetically differentiated among most of their host plants. Comparison of branch lengths between the T. coweni clade and the T. inquilinus clade indicates that the T. inquilinus lineage evolves 2.5-3 times faster for the cytochrome oxidase I gene. These results demonstrate that: (1) Tamalia inquilines originated from their gall-inducing hosts, (2) communal (multi-female) gall induction apparently facilitated the origin of inquilinism, (3) diversification of the inquilines has involved rapid speciation along host-plant lines, or the rapid evolution of host-plant races, and (4) the inquilines have undergone accelerated molecular evolution relative to their hosts, probably due to reduced effective population sizes. Our findings provide insight into the behavioural causes and evolutionary consequences of transitions from resource generation to resource exploitation.
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Affiliation(s)
- D G Miller
- Department of Biological Sciences, California State University-Chico, Chico, CA, USA
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Parker Ward R, Miller DG, Collins KA, DeCara JM, Spencer KT, Mor-Avi V, Lang RM. The effects of harmonic imaging on endocardial visualization during transesophageal echocardiography. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)82515-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Sustained high notes, diminishing gradually from the loudest to the softest phonation within a maneuver called messa di voce, are examined in two contrasting professional tenor voices. Signals of the sound pressure level, electroglottograph, and mean esophageal pressure are recorded, and similar maneuvers by the same subjects are examined stroboscopically. The lyric voice is found to make a gradual diminuendo while maintaining nearly constant posture of the vocal tract together with a phase of complete closure in the glottal cycle. The robust voice, by contrast, passes abruptly from a production of high subglottal pressure and a high closed quotient to one of low pressure and incomplete closure, and the transition is marked by a sudden opening of the previously constricted laryngeal collar. It is proposed that the mode of soft voice production demonstrated by the robust voice be recognized as a distinct register of the singing voice.
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Affiliation(s)
- D G Miller
- Groningen Voice Research Laboratory, Biomedical Engineering, University of Groningen, The Netherlands.
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Abstract
High myopia, or pathologic myopia, usually refers to a condition in which individuals have greater than 6 diopters of myopia or an axial length greater than 26 to 27 mm. The natural history of choroidal neovascularization in high myopia is variable, and reports to date have some conflicting information, but analysis shows fairly poor final visual outcomes. This outcome complicates recommendations for treatment and must be considered in future studies aimed at managing this disease.
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Affiliation(s)
- D G Miller
- Retina Associates of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA.
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Miller DG, Brayton SV, Boyles WT. Chemical oxygen demand analysis of wastewater using trivalent manganese oxidant with chloride removal by sodium bismuthate pretreatment. Water Environ Res 2001; 73:63-71. [PMID: 11558305 DOI: 10.2175/106143001x138705] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Current chemical oxygen demand (COD) analyses generate wastes containing hexavalent and trivalent chromium, mercury, and silver. Waste disposal is difficult, expensive, and poses environmental hazards. A new COD test is proposed that eliminates these metals and shortens analysis time, where trivalent manganese oxidant replaces hexavalent chromium (dichromate). A silver catalyst is not required. Optional pretreatment removes chloride via oxidation to chlorine using sodium bismuthate, eliminating the need for mercury. Sample aqueous and solid components are separated for chloride removal, then recombined for total COD measurement. Soluble and nonsoluble COD can be determined separately. Digestion at 150 degrees C is complete in 1 hour. Results are determined by titration or by spectrophotometric reading. Test wastes contain none of the metals regulated for disposal under the Resource Conservation and Recovery Act. Results are shown for selected organic compounds and various wastewaters. Statistical comparisons are made with dichromate COD and biochemical oxygen demand (BOD5) test values.
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Affiliation(s)
- D G Miller
- Analytical Services Group, Hach Company, 100 Dayton Avenue, Ames, IA 50010, USA
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Abstract
In the past five years the advent of cancer genetic testing has created concern about the negative psychosocial sequelae of genetic counseling and testing. Research indicates that the women most likely to seek genetic testing are anxious about carrying a gene mutation and developing breast cancer. Women who are at high risk have poor knowledge and the expectation of being a gene-mutation carrier. High levels of distress have been shown to interfere with decision-making about genetic testing. Further, individuals who decline genetic testing may be at increased risk for depressive symptoms even more than those who are found to be gene-mutation carriers. There is great concern that inappropriate candidates will seek genetic testing. Improved education and access to genetic counseling are essential to help women make appropriate decisions about genetic testing. Strategies for the prevention of breast and ovarian cancer are explored, and methods to reduce the adverse psychosocial effects of decision-making about genetic testing and preventive treatment strategies are suggested.
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Affiliation(s)
- K M Kash
- Beth Israel Medical Center, New York, New York, USA.
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Martidis A, Miller DG, Ciulla TA, Danis RP, Moorthy RS. Corticosteroids as an antiangiogenic agent for histoplasmosis-related subfoveal choroidal neovascularization. J Ocul Pharmacol Ther 1999; 15:425-8. [PMID: 10530703 DOI: 10.1089/jop.1999.15.425] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to evaluate the role of corticosteroids in managing subfoveal choroidal neovascularization (CNV) secondary to the presumed ocular histoplasmosis syndrome. The cases of eighteen patients with histoplasmosis-related subfoveal CNV treated with corticosteroids were reviewed. Ten patients received oral prednisone for 4 to 6 weeks, and eight received a single sub-Tenon's injection of triamcinalone. Visual acuity outcomes were analyzed along with side effect profiles. At two-week follow-up, the prednisone group showed a median improvement in Snellen visual acuity of +2.0 lines, while the triamcinalone group remained essentially stable with a 0.5 line median loss. At treatment end (4 to 6 weeks), both groups showed no significant change in median acuity at 0.0 and -1.0 lines, respectively. Median final vision at 3 months also remained essentially stable at -0.5 lines for each group. Three patients reported anxiety, all of whom were taking prednisone 80 mg daily. Two patients reported increased appetite and weight gain on regimens of prednisone 80 and 100 mg daily. There were no adverse effects reported in the other patients receiving oral prednisone or in any patient receiving sub-Tenon's triamcinalone. The results suggest a beneficial effect of corticosteroids in stabilizing subfoveal CNV secondary to ocular histoplasmosis. In this small series, oral prednisone resulted in a short-term improvement in visual acuity, which stabilized over longer follow-up. The sub-Tenon's triamcinalone group achieved similar final stabilization without the initial improvement. Corticosteroids may be particularly valuable in managing neovascularization in patients who are awaiting interventions currently under development, in preventing recurrence after subfoveal surgery, or in treating non-surgical candidates. Further study is warranted to define the precise role of corticosteroids in this condition.
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Affiliation(s)
- A Martidis
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis 46202, USA
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Svec JG, Schutte HK, Miller DG. On pitch jumps between chest and falsetto registers in voice: data from living and excised human larynges. J Acoust Soc Am 1999; 106:1523-31. [PMID: 10489708 DOI: 10.1121/1.427149] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The paper offers a new concept of studying abrupt chest-falsetto register transitions (jumps) based on the theory of nonlinear dynamics. The jumps were studied in an excised human larynx and in three living subjects (one female and two male). Data from the excised larynx revealed that a small and gradual change in tension of the vocal folds can cause an abrupt change of register and pitch. This gives evidence that the register jumps are manifestations of bifurcations in the vocal-fold vibratory mechanism. A hysteresis was observed; the upward register jump occurred at higher pitches and tensions than the downward jump. Due to the hysteresis, the chest and falsetto registers can be produced with practically identical laryngeal adjustments within a certain range of longitudinal tensions. The magnitude of the frequency jump was measured as the "leap ratio" F0F:F0C (fundamental frequency of the falsetto related to that of the chest register) and alternatively expressed as a corresponding musical interval, termed the "leap interval." Ranges of this leap interval were found to be different for the three living subjects (0-5 semitones for the female, 5-10 and 10-17 for the two males, respectively). These differences are considered to reflect different biomechanical properties of the vocal folds of the examined subjects. A small magnitude of the leap interval was associated with a smooth chest-falsetto transition in the female subject.
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Affiliation(s)
- J G Svec
- Centre for Communication Disorders, Medical Healthcom, Ltd., Prague, Czech Republic.
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Affiliation(s)
- D G Miller
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston 02114, USA
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Miller DG, Tiwari R, Pathak S, Hopwood VL, Gilbert F, Hsu TC. DNA repair and mutagen sensitivity in patients with triple primary cancers. Cancer Epidemiol Biomarkers Prev 1998; 7:321-7. [PMID: 9568788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The purpose of this study was to measure DNA repair capacity and mutagen sensitivity in patients who have had three or more primary forms of cancer. It was hypothesized that, if abnormalities in DNA repair and mutagen sensitivity were cancer susceptibility factors, such findings would be seen with regularity in individuals with multiple primary cancers. DNA repair capacity was measured by determining repair of UV-irradiated plasmid DNA (pCMVCAT) transfected into peripheral blood lymphocytes. Results from 18 patients and a like number of age- and sex-matched controls demonstrated a significant difference in DNA repair capacity (P < 0.0001; odds ratio = 14). Mutagen sensitivity was measured by determining the mean number of chromatid breaks per cell after in vitro exposure to either bleomycin or 4-nitroquinoline-1-oxide. The difference in mean bleomycin- or 4-nitroquinoline-1-oxide-induced mutagen sensitivity between cases and controls was not statistically significant. Fourteen of the 18 patients had positive family histories of cancer; in 10, the history was compatible with cancer susceptibility syndromes. Although the numbers were small, there was no suggestion in this study that treatment or the presence of cancer was the cause of the DNA repair abnormalities encountered. These findings support the concept of diminished DNA repair capacity as an underlying feature in the development of a mutator phenotype.
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Affiliation(s)
- D G Miller
- Strang Cancer Prevention Center, New York, New York 10021, USA
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Abstract
The skilled use of nonperiodic phonation techniques in combination with spectrum analysis has been proposed here as a practical method for locating formant frequencies in the singing voice. The study addresses the question of the degree of similarity between sung phonations and their nonperiodic imitations, with respect to both frequency of the first two formants as well as posture of the vocal tract. Using magnetic resonance imaging (MRI), linear predictive coding (LPC), and spectrum analysis, two types of nonperiodic phonation (ingressive and vocal fry) are compared with singing phonations to determine the degree of similarity/difference in acoustic and spatial dimensions of the vocal tract when these phonation types are used to approximate the postures of singing. In comparing phonation types, the close similarity in acoustic data in combination with the relative dissimilarity in spatial data indicates that the accurate imitations are not primarily the result of imitating the singing postures, but have instead an aural basis.
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Affiliation(s)
- D G Miller
- Department of Medical Physiology, University Hospital Groningen, The Netherlands
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Antani MR, Beyth RJ, Covinsky KE, Anderson PA, Miller DG, Cebul RD, Quinn LM, Landefeld CS. Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation. J Gen Intern Med 1996; 11:713-20. [PMID: 9016417 DOI: 10.1007/bf02598984] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine how often warfarin was prescribed to patients with nonrheumatic atrial fibrillation in our community in 1992 when randomized trials had demonstrated that warfarin could prevent stroke with little increase in the rate of hemorrhage, and to determine whether warfarin was prescribed less frequently to older patients-the patients at highest risk of stroke but of most concern to physicians in terms of the safety of warfarin. DESIGN Cross-sectional study. Appropriateness of warfarin was classified for each patient based on the independent judgments of three physicians applying relevant evidence and guidelines. SETTING Two teaching hospitals and five community-based practices. PATIENTS Consecutive patients with nonrheumatic atrial fibrillation (n = 189). MEASUREMENTS AND MAIN RESULTS Warfarin was prescribed to 44 (23%) of the 189 patients. Warfarin was judged appropriate in 98 patients (52%), of whom 36 (37%) were prescribed warfarin. Warfarin was prescribed to 11 (14%) of 76 patients aged 75 years or older with hypertension, diabetes mellitus, or past stroke, the group at highest risk of stroke. In a multivariable logistic regression model controlling for appropriateness of warfarin and other patient characteristics, patients aged 75 years or older were less likely than younger patients to be treated with warfarin (odds ratio 0.25; 95% confidence interval 0.10, 0.65). CONCLUSIONS Warfarin was prescribed infrequently to these patients with nonrheumatic atrial fibrillation, especially the older patients and even the patients for whom warfarin was judged appropriate. These findings indicate a substantial opportunity to prevent stroke.
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Affiliation(s)
- M R Antani
- Division of General Internal Medicine, Cleveland Veterans Affairs Medical Center, OH 44106, USA
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Beyth RJ, Antani MR, Covinsky KE, Miller DG, Chren MM, Quinn LM, Landefeld CS. Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation? J Gen Intern Med 1996; 11:721-8. [PMID: 9016418 DOI: 10.1007/bf02598985] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the opinions of selected physicians in our community about use of warfarin for patients with nonrheumatic atrial fibrillation, and to determine the relation of the physicians' opinions to their practices. DESIGN Survey of physicians, using eight hypothetical clinical vignettes to characterize physicians' opinions about use of warfarin in patients with nonrheumatic atrial fibrillation, according to patient age, risk of bleeding, and risk of stroke. SETTING Two teaching hospitals and five community-based practices. PARTICIPANTS Eighty physicians who cared for 189 consecutive patients with nonrheumatic atrial fibrillation. MEASUREMENTS AND MAIN RESULTS The survey response rate was 73%. Nearly all responding physicians (90%) recommended warfarin for at least one vignette. However, physicians recommended warfarin less often for vignettes depicting 85-year-old patients than for matched vignettes depicting 65-year-old patients (odds ratio [OR] 0.03; 95% confidence interval [CI] 0.01, 0.08), and less often for cases with specified risk factors for bleeding than for matched cases without the risk factors (OR 0.01; 95% CI 0.004, 0.03); warfarin was recommended more often for cases with a recent stroke than for matched cases without this history (OR 8.2; 95% CI 3.6, 18). In practice, warfarin was prescribed more often (p < or = .05) by physicians reporting good personal experience and by those who had favorable opinions about its use. However, even physicians with good experience and favorable opinions did not prescribe warfarin to half of their patents for whom warfarin was independently judged appropriate. CONCLUSIONS Physicians' opinions frequently opposed warfarin for older patients with nonrheumatic atrial fibrillation, and for those with bleeding risk factors. Physicians' opinions, as well as other barriers to warfarin therapy, most likely contribute to its infrequent prescription.
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Affiliation(s)
- R J Beyth
- Division of General Internal Medicine, Cleveland Veterans Affairs Medical Center, OH 44106, USA
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