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Patel N, Greene N, Guynn N, Sharma A, Toleva O, Mehta PK. Ischemia but no obstructive coronary artery disease: more than meets the eye. Climacteric 2024; 27:22-31. [PMID: 38224068 DOI: 10.1080/13697137.2023.2281933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/31/2023] [Indexed: 01/16/2024]
Abstract
Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.
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Affiliation(s)
- N Patel
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - N Greene
- Emory University School of Medicine, Atlanta, GA, USA
| | - N Guynn
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - A Sharma
- Department of Internal Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - O Toleva
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - P K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
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Greene N, Quéré S, Bury DP, Mazerolle F, M'Hari M, Loubert A, Regnault A, Higuchi K. Establishing clinically meaningful within-individual improvement thresholds for eight patient-reported outcome measures in people with relapsing-remitting multiple sclerosis. J Patient Rep Outcomes 2023; 7:61. [PMID: 37402086 DOI: 10.1186/s41687-023-00594-8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/22/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND As disease-modifying therapies do not reverse the course of multiple sclerosis (MS), assessment of therapeutic success involves documenting patient-reported outcomes (PROs) concerning health-related quality of life, disease and treatment-related symptoms, and the impact of symptoms on function. Interpreting PRO data involves going beyond statistical significance to calculate within-patient meaningful change scores. These thresholds are needed for each PRO in order to fully interpret the PRO data. This analysis of PRO data from the PROMiS AUBAGIO study, which utilized 8 PRO instruments in teriflunomide-treated relapsing-remitting MS (RRMS) patients, was designed to estimate clinically meaningful within-individual improvement thresholds in the same manner, for 8 PRO instruments. RESULTS The analytical approach followed a triangulation exercise that considered results from anchor- and distribution-based methods and graphical representations of empirical cumulative distribution functions in PRO scores in groups defined by anchor variables. Data from 8 PRO instruments (MSIS-29 v2, FSMC, MSPS, MSNQ, TSQM v1.4, PDDS, HRPQ-MS v2, and HADS) were assessed from 434 RRMS patients. For MSIS-29 v2, FSMC, MSPS, and MSNQ total scores, available anchor variables enabled both anchor- and distribution-based methods to be applied. For instruments with no appropriate anchor available, distribution-based methods were applied. A recommended value for meaningful within-individual improvement was defined by comparing mean change in PRO scores between participants showing improvement of one or two categories in the anchor variable or those showing no change. A "lower bound" estimate was calculated using distribution-based methods. An improvement greater than the lower-bound estimate was considered "clinically meaningful". CONCLUSION This analysis produced estimates for assessing meaningful within-individual improvements for 8 PRO instruments used in MS studies. These estimates should be useful for interpreting scores and communicating study results and should facilitate decision-making by regulatory and healthcare authorities where these 8 PROs are commonly employed.
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Affiliation(s)
| | | | | | | | - Manal M'Hari
- Modus Outcomes, A Division of THREAD, Lyon, France
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Araujo L, Kyatham S, Bzdek KG, Higuchi K, Greene N. Assessing the Health Economic Outcomes from Commercially Insured Relapsing Multiple Sclerosis Patients Who Switched from Other Disease-Modifying Therapies to Teriflunomide, in the United States. Clinicoecon Outcomes Res 2023; 15:361-373. [PMID: 37234086 PMCID: PMC10208242 DOI: 10.2147/ceor.s401687] [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: 01/27/2023] [Accepted: 05/02/2023] [Indexed: 05/27/2023] Open
Abstract
Objective Assess patient characteristics, healthcare resource utilization (HCRU), and relapses in patients with multiple sclerosis (MS) who switched to teriflunomide from other disease-modifying therapies (DMTs). Methods Retrospective study of US Merative™ MarketScan® claims database (Jan 1, 2012-July 31, 2020,) including HIPAA-compliant, deidentified data. Patients ≥18 years with MS diagnosis (based on ICD-9/ICD-10 codes), receiving ≥1 DMT prior to teriflunomide and ≥12 months continuous enrollment pre and post index (date of teriflunomide initiation). Outcomes included inpatient and emergency room claims coinciding with MS diagnosis, MS-related healthcare costs, and annualized relapse rates (ARRs) (indirectly assessed using hospitalization/outpatient claims and steroid use coinciding with MS diagnosis). Results The analyzed cohort (N=2016) was primarily female (79%); age (mean ± standard deviation) 51.4 ± 9.3 years; MS duration 4.7±2.8 years (at index). The majority (89.2%) were treated with one DMT before switching to teriflunomide. Use of outpatient services (event rate/100 person-years) increased post vs pre index; however, MRI visits significantly reduced over the same period (both P<0.0001). Costs for MS-specific outpatient visits decreased by $371 per patient per year (PPPY) after switching to teriflunomide. Despite an increase in use post index (0.024 to 0.033 rate/100 person-years; P<0.0001), costs for MS-specific laboratory services reduced (pre-index: $271 vs $248 PPPY post-index; P=0.02). Fewer patients had relapses after switching (pre-index: n=417 [20.7%]; post-index: n=333 [16.5%]). ARR was significantly lower after switching (pre-index: 0.269 vs post-index: 0.205; P=0.000). Conclusion Switching to teriflunomide from existing DMTs in patients with relapsing MS resulted in a reduction in outpatient HCRU in this analysis of US claims data. The real-world effectiveness of teriflunomide was generally consistent with efficacy reported in clinical trials, showing a reduction in relapse following a switch to teriflunomide.
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Affiliation(s)
- Lita Araujo
- Neurology and Immunology, Sanofi, Cambridge, MA, USA
| | | | | | - Keiko Higuchi
- Neurology and Immunology, Sanofi, Cambridge, MA, USA
| | - Nupur Greene
- Neurology and Immunology, Sanofi, Cambridge, MA, USA
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Araujo L, Kyatham S, Bzdek KG, Higuchi K, Greene N. Health economic outcomes of switching to alemtuzumab from other disease-modifying therapies in people with multiple sclerosis in the USA. J Comp Eff Res 2023; 12:e220127. [PMID: 36440609 PMCID: PMC10288951 DOI: 10.2217/cer-2022-0127] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Aim: Describe demographics, clinical characteristics, healthcare resource utilization (HCRU) and costs in people with multiple sclerosis (pwMS) switching to alemtuzumab from other disease-modifying therapies (DMTs). Patients & methods: Retrospective, observational study of IBM®MarketScan® claims database. PwMS previously treated with DMTs and initiating alemtuzumab (1 January 2013 to 31 December 2019) were identified. "Index" was date of alemtuzumab initiation (prescription filled). Results: The study cohort (n = 341) was primarily female (72%) with (mean ± standard deviation) age 45.1 ± 9.5 years. At index, duration of MS was 5.3 ± 2.8 years. HCRU (inpatient/outpatient services), outpatient costs (including MS-specific MRI and emergency room visits) and annualized relapse rate significantly reduced over the 2 years following initiation of alemtuzumab. DMT costs reduced over the same period. Conclusion: Health economic and clinical benefits were seen following switching to alemtuzumab from other DMTs for treatment of MS, in this cohort from the USA.
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Greene N, Higuchi K, Bognar K, Chang E, Broder MS. Medication Adherence and Healthcare Utilization in Relapsing-Remitting Multiple Sclerosis Patients Using Teriflunomide. Clinicoecon Outcomes Res 2022; 14:755-761. [PMID: 36578311 PMCID: PMC9791931 DOI: 10.2147/ceor.s383934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose Multiple sclerosis (MS) is a costly, immune-mediated disease of the central nervous system. Most patients have relapsing-remitting MS (RRMS) for which disease-modifying therapies (DMTs) provide an effective treatment option by reducing relapse rates. However, adherence to DMTs is suboptimal. This study examines the association between adherence to teriflunomide and clinical and healthcare utilization outcomes. Patients and Methods Patients with RRMS who started treatment with teriflunomide between 1/1/2018 and 12/31/2019 were analyzed using IQVIA PharMetrics® Plus data. RRMS patients were identified via diagnosis codes and treatment types; the first prescription date for teriflunomide was the index date. Highly and poorly adherent patients were identified based on the proportion of days covered (PDC) post-index (PDC ≥0.8 and PDC ≤0.5, respectively). Patient demographics, clinical characteristics, healthcare utilization during the year pre- and post-index, and relapse rate post-index were reported descriptively. Outcomes were compared between highly and poorly adherent patients through logistic regression. Models were adjusted for demographics, comorbidities, and utilization measures during the baseline period. Results Among the 922 RRMS patients identified, 534 (57.9%) were highly adherent to teriflunomide, while 249 (27.0%) had PDC ≤0.5. The two groups were not statistically different in terms of demographic characteristics and comorbidities; however, poorly adherent patients were more likely to have emergency department (ED) or inpatient visits during baseline (36.9% versus 26.8%, P=0.004; 17.3% versus 10.9%, P=0.013, respectively). Unadjusted results suggested lower likelihood of both relapses and utilization during follow-up among highly adherent patients compared to poorly adherent patients. Adjusted results confirmed that high adherence was associated with decreased likelihood of post-index relapses, ED utilization, and inpatient utilization (OR [95% CI]: 0.55 [0.39-0.76], 0.49 [0.34-0.71], and 0.51 [0.27-0.97], respectively) even after controlling for baseline utilization. Conclusion High adherence to teriflunomide was found to be associated with fewer relapses and lower healthcare utilization among patients with RRMS.
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Affiliation(s)
- Nupur Greene
- Neurology & Immunology (N&I), Sanofi, Cambridge, MA, USA,Correspondence: Nupur Greene, Global HEVA Business Partner, N&I, Sanofi, 450 Water Street, Cambridge, MA, USA, Tel +1 857 259 0037, Email
| | - Keiko Higuchi
- Neurology & Immunology (N&I), Sanofi, Cambridge, MA, USA
| | - Katalin Bognar
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA, USA
| | - Eunice Chang
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA, USA
| | - Michael S Broder
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA, USA
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Greene N, Araujo L, Campos C, Dalglish H, Gibbs S, Yermilov I. The Economic and Humanistic Burden of Pediatric-Onset Multiple Sclerosis. J Health Econ Outcomes Res 2022; 9:103-114. [PMID: 36348724 PMCID: PMC9584745 DOI: 10.36469/001c.37992] [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] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/29/2022] [Indexed: 06/16/2023]
Abstract
Background: Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease of the central nervous system. Pediatric-onset MS (POMS), defined as onset of MS before 18 years of age, is estimated to account for 2% to 5% of the MS population worldwide. Objectives: To conduct a literature review focused on the healthcare resource utilization and cost as well as quality-of-life (QOL) outcomes among patients with POMS. Methods: We conducted a systematic literature review of English-language studies published after September 2010 in MEDLINE and Embase to describe the global economic healthcare resource utilization and costs and humanistic (QOL) burden in patients with POMS. Results: We found 11 studies that reported on healthcare resource utilization, cost, or insurance coverage and 36 studies that reported on QOL outcomes in patients with POMS. Patients with POMS had higher rates of primary care visits (1.41 [1.29-1.54]), hospital visits (10.74 [8.95-12.90]), and admissions (rate ratio, 4.27 [2.92-6.25];OR, 15.2 [12.0-19.1]) compared with healthy controls. Mean per-patient costs in the United States were $5907 across all settings per year of follow-up between 2002 and 2012; mean costs per hospital stay were $38 543 (in 2015 USD) between 2004 and 2013. Three studies reported psychosocial scores between 71.59 and 79.7, and 8 studies reported physical health scores between 74.62 to 82.75 using the Pediatric Quality of Life Measurement Model (PedsQLTM). Twelve studies used the PedsQL™ Multidimensional Fatigue Scale. Mean scores on the self-reported general fatigue scale ranged from 63.15 to 78.5. Quality-of-life scores were lower than those of healthy controls. Discussion: Our review presents a uniquely broad and recent overview of the global economic and humanistic burden of patients with POMS. Additional research on healthcare resource utilization and cost would provide a more robust understanding of the economic burden in this population. Conclusions: Healthcare resource utilization and costs are high in this population, and patients report reduced QOL and significant fatigue compared with healthy children and adolescents.
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Affiliation(s)
- Nupur Greene
- Health Economics & Value Assessment, Sanofi, Cambridge, Massachusetts
| | - Lita Araujo
- Health Economics & Value Assessment, Sanofi, Cambridge, Massachusetts
| | - Cynthia Campos
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| | - Hannah Dalglish
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| | - Sarah Gibbs
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
| | - Irina Yermilov
- PHAR (Partnership for Health Analytic Research), LLC, Beverly Hills, California
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Bhattacharjee S, Yegezu Z, Kollecas K, Duhrkopf K, Hashemi L, Greene N. Influence of Comorbidities on Healthcare Expenditures and Perceived Physical and Mental Health Status Among Adults with Multiple Sclerosis: A Propensity Score-Matched US National-Level Study. Clinicoecon Outcomes Res 2021; 13:377-394. [PMID: 34017188 PMCID: PMC8129918 DOI: 10.2147/ceor.s305154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/30/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To evaluate the effect of comorbidities on healthcare expenditures and perceived physical and mental health status among adults with multiple sclerosis (MS) compared to propensity score-matched non-MS controls. Methods A retrospective, cross-sectional, matched cohort study was conducted using Medical Expenditure Panel Survey (2005–2015) data. The base study sample consisted of adults (age ≥18 years) who were alive and had positive total healthcare expenditures during the survey calendar year. Adults with MS were propensity-matched (1:1) to non-MS controls based on age, gender, and race/ethnicity using greedy matching algorithm. Healthcare expenditures consisted of total and subtypes of expenditures. Health status consisted of perceived physical and mental health status. Comorbidities were identified using ICD-9-CM and Clinical Classification System codes. Ordinary least squares regression and multinomial logistic regression were used to analyze the healthcare expenditures and health status variables, respectively. Results Final study sample consisted of 541 adults in each MS and non-MS control groups after propensity score matching. After adjusting for potential confounders, individuals with MS had greater total and subtypes of expenditures compared to non-MS controls, and several comorbidities (eg, depression, hypertension) were significantly associated with increased healthcare expenditures. Yearly average total expenditures (expressed in 2018 US$) were significantly (p<0.001) higher for adults with MS ($29,396) than propensity score-matched non-MS adults ($7875). Moreover, after adjusting for all individual-level factors, adults with MS experienced 363% (p<0.001) higher total expenditures compared to propensity score-matched non-MS controls. Individuals with MS were more likely to report poorer physical and good mental health status compared to propensity score-matched non-MS controls, and several comorbidities (eg, anxiety, depression) were significant independent predictors of poorer health status. For example, adults with MS were four times more likely (OR: 4.10, 95% CI: 2.42–6.96) to report fair/poor physical health status compared to excellent/very good physical health status compared with non-MS controls. Adults with MS were 42% (OR: 1.42, 95% CI: 1.01–1.99) more likely than propensity score-matched non-MS controls to report good rather than very good or excellent mental health status. However, there was no difference between adults with MS and propensity score-matched non-MS controls in terms of reporting fair or poor than very good or excellent mental health status. Conclusion Findings from this study indicate substantial economic and health status burdens among adults with MS at the US national-level that are significantly influenced by comorbidities.
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Affiliation(s)
- Sandipan Bhattacharjee
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Zufan Yegezu
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ, USA
| | - Kristin Kollecas
- Neurology, Immunology, & Inflammation, Sanofi Genzyme, Cambridge, MA, USA
| | - Kevin Duhrkopf
- Neurology, Immunology, & Inflammation, Sanofi Genzyme, Cambridge, MA, USA
| | - Lobat Hashemi
- Neurology, Immunology, & Inflammation, Sanofi Genzyme, Cambridge, MA, USA
| | - Nupur Greene
- Neurology, Immunology, & Inflammation, Sanofi Genzyme, Cambridge, MA, USA
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Griffin J, Macgregor B, Greene N, Partridge CR, Bryson J, Schoof RA. Letter to the Editor regarding Davis B, McDermott S, McCarter M, Ortaglia A. 2019. Population-based mortality data suggests remediation is modestly effective in two Montana Superfund counties. Environ. Geochem. Health. Environ Geochem Health 2020; 42:1229-1233. [PMID: 31673915 DOI: 10.1007/s10653-019-00438-9] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Affiliation(s)
- J Griffin
- Butte Resident, Butte-Silver Bow County, MT, USA
| | - B Macgregor
- Butte Resident, Butte-Silver Bow County, MT, USA
| | - N Greene
- U.S. Environmental Protection Agency Region 8, Denver, CO, USA
| | - C R Partridge
- U.S. Environmental Protection Agency Region 8, Denver, CO, USA
| | - J Bryson
- , Atlantic Richfield, Butte, MT, USA
| | - R A Schoof
- Ramboll US Corporation, 901 Fifth Avenue, Suite 2820, Seattle, WA, 98164, USA.
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Siedhoff M, Wright K, Misal M, Molina A, Greene N. 23: Postoperative urinary retention following benign gynecologic surgery with a liberal vs. strict voiding protocol. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.12.063] [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] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kathiresan A, Wang E, Greene N, Alexander C, Pisarska M. Abnormal implantation in day 3 versus day 5 embryo transfers in fresh IVF cycles: an analysis from the society for assisted reproductive technology database. Fertil Steril 2015. [DOI: 10.1016/j.fertnstert.2015.07.307] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wang E, Ozimek J, Greene N, Ramos L, Vyas N, Kilpatrick S, Pisarska M. Impact of ART on severe maternal morbidity. Fertil Steril 2015. [DOI: 10.1016/j.fertnstert.2015.07.672] [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] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ramos L, Wang E, Greene N, Vyas N, Pisarska M. Mode of conception is not associated with adverse pregnancy outcomes. Fertil Steril 2015. [DOI: 10.1016/j.fertnstert.2015.07.659] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Greene N, Lassen CF, Rugbjerg K, Ritz B. Reproductive factors and Parkinson's disease risk in Danish women. Eur J Neurol 2014; 21:1168-77, e68. [PMID: 24750445 DOI: 10.1111/ene.12450] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [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: 11/26/2013] [Accepted: 03/17/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Parkinson's disease is more common in men than women by a ratio of about 1.5:1 and yet there is no consensus to date as to whether female reproductive factors including hormone use affect Parkinson's disease risk. Our objective was to examine the relationship between Parkinson's disease and female reproductive factors in the largest population-based Parkinson's disease case-control study to date. METHODS Seven hundred and forty-three female Parkinson's disease cases diagnosed between 1996 and 2009 were selected from the Danish National Hospital Register, diagnoses confirmed by medical record review, and the cases were matched by birth year to 765 female controls randomly selected from the Danish Civil Registration System. Covariate information was collected in computer-assisted telephone interviews covering an extensive array of topics including reproductive and lifestyle factors. RESULTS After adjusting for smoking, caffeine and alcohol use, education, age, and family Parkinson's disease history, inverse associations between Parkinson's disease and early menarche (first period at ≤11 years), oral contraceptives, high parity (≥4 children) and bilateral oophorectomy were found; adjusted odds ratios and 95% confidence limits were respectively 0.68 (0.45-1.03) for early menarche, 0.87 (0.69-1.10) for oral contraceptives, 0.79 (0.59-1.06) for high parity and 0.65 (0.45-0.94) for bilateral oophorectomy. Little support for associations between Parkinson's disease and fertile life length, age at menopause or post-menopausal hormone treatment was found. CONCLUSIONS Reproductive factors related to women's early- to mid-reproductive lives appear to be predictive of subsequent Parkinson's disease risk whereas factors occurring later in life seem less important.
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Affiliation(s)
- N Greene
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Lachmann R, Picciarelli G, Moratalla J, Greene N, Nicolaides KH. Frontomaxillary facial angle in fetuses with spina bifida at 11-13 weeks' gestation. Ultrasound Obstet Gynecol 2010; 36:268-271. [PMID: 20549771 DOI: 10.1002/uog.7718] [Citation(s) in RCA: 34] [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] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To determine whether in fetuses with open spina bifida at 11-13 weeks' gestation the frontomaxillary facial angle is decreased. METHODS The frontomaxillary facial angle was measured in 20 fetuses with open spina bifida and in 100 normal controls matched for crown-rump length (CRL) at 11 + 0 to 13 + 6 weeks and the values in the two groups were compared. RESULTS In the control group the frontomaxillary facial angle decreased significantly with CRL from a mean of 84.0 degrees at a CRL of 45 mm to 76.5 degrees at a CRL of 84 mm (SD, 3.26 degrees). In the spina bifida group the mean frontomaxillary facial angle, corrected for CRL, was 9.9 degrees lower than in the controls and it was below the 5(th) centile in 18 (90%) of the cases (P < 0.0001). CONCLUSIONS In fetuses with open spina bifida at 11-13 weeks' gestation the frontomaxillary facial angle is decreased and this measurement may be useful in early screening for this abnormality.
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Affiliation(s)
- R Lachmann
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Fisk L, Greene N, Naven R, Patel M. Investigation of structure–activity relationships for mitochondrial toxicity. Toxicol Lett 2010. [DOI: 10.1016/j.toxlet.2010.03.694] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Webb C, Quinn J, Greene N. A 4-year review of aeroallergen immunotherapy reactions. J Allergy Clin Immunol 2003. [DOI: 10.1016/s0091-6749(03)80541-9] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Snijders RJM, Thom EA, Zachary JM, Platt LD, Greene N, Jackson LG, Sabbagha RE, Filkins K, Silver RK, Hogge WA, Ginsberg NA, Beverly S, Morgan P, Blum K, Chilis P, Hill LM, Hecker J, Wapner RJ. First-trimester trisomy screening: nuchal translucency measurement training and quality assurance to correct and unify technique. Ultrasound Obstet Gynecol 2002; 19:353-359. [PMID: 11952964 DOI: 10.1046/j.1469-0705.2002.00637.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [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
OBJECTIVE To describe the process of training for measuring nuchal translucency at five clinical centers in North America and to evaluate methods of quality assurance and feedback. DESIGN Throughout a period of 18 months, the performance of sonographers in measuring fetal nuchal translucency was monitored using qualitative and quantitative methods of review. After 12 months, different approaches (written and personal feedback) were used to inform sonographers of technical aspects that needed to or could be improved. RESULTS On initial qualitative review, discrepancies in judgment from different reviewers coincided with suboptimal magnification, failure to visualize the amniotic membrane and/or use of cross-shaped calipers. At subsequent global review, 13 (29%) images of nuchal translucency measurements were considered unacceptable. Quantitative assessment revealed that, during the first part of the study, the means from four sonographers were significantly smaller and the mean from the fifth sonographer was significantly larger than expected on the basis of findings from The Fetal Medicine Foundation (P < 0.0001). Following feedback, sonographers who underestimated nuchal translucency and who received a written report only did not change measurements overall (P = 0.9759). In contrast, those who received additional intervention showed a marked difference (P < 0.0001). CONCLUSIONS Global qualitative review of images from one sonographer may be preferable to assessment of individual aspects of images. Results from global qualitative review correspond well with findings from quantitative analysis, indicating that the latter can be applied for ongoing audit. Observation of divergent results should prompt extensive personal feedback, rather than a written report, to prevent sonographers from settling in their own, inappropriate technique.
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Affiliation(s)
- R J M Snijders
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Strocker AM, Snijders RJ, Carlson DE, Greene N, Gregory KD, Walla CA, Platt LD. Fetal echogenic bowel: parameters to be considered in differential diagnosis. Ultrasound Obstet Gynecol 2000; 16:519-523. [PMID: 11169344 DOI: 10.1046/j.1469-0705.2000.00241.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [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
OBJECTIVES To evaluate the extent that associated findings aid in the differential diagnosis and/or prognosis of fetal echogenic bowel. METHODS Medical history, obstetric records and outcome details were examined for 131 consecutive pregnancies with fetal hyperechogenic bowel. RESULTS In 62 (47%) cases, there were no visible anomalies other than hyperechogenic bowel and no evidence of growth restriction. This group included four (7%) pregnancies with Down syndrome, 15 (24%) with infection or a recent episode of influenza and eight (13%) with blood staining of amniotic fluid. In the remaining 69 (53%) cases, hyperechogenic bowel was accompanied by hydrops or nuchal edema (n = 16, 12.2%), growth restriction (n = 9, 6.9%), other markers for chromosome anomalies (n = 33, 25.2%) or multiple structural anomalies (n = 11, 8.4%). In this group, the prevalence of Down syndrome was 12%, infection or influenza was reported in 14 (20%) cases and there was blood staining of amniotic fluid in seven (10%). Cystic fibrosis screening was performed in 65 (50%) pregnancies; the results were negative in all cases and clinical assessment did not indicate cystic fibrosis in any of the 91 infants who were born alive. Maternal serum screening was performed in 41 (31%) pregnancies. High alpha-fetoprotein levels were associated with multiple abnormalities or severe growth restriction. CONCLUSIONS In many pregnancies with fetal hyperechogenic bowel, there are multiple factors that may explain these findings. Thus identification of one potential underlying cause should not preclude further testing. Once chromosome defects, cystic fibrosis, structural abnormalities, infection and growth restriction have been excluded, parents can be counseled that the prognosis is good, irrespective of the presence or absence of blood stained amniotic fluid.
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Affiliation(s)
- A M Strocker
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center Burns & Allen Research Institute, UCLA School of Medicine, Los Angeles, CA, USA
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Snijders RJ, Platt LD, Greene N, Carlson D, Krakow D, Gregory K, Bradley K. Femur length and trisomy 21: impact of gestational age on screening efficiency. Ultrasound Obstet Gynecol 2000; 16:142-145. [PMID: 11117083 DOI: 10.1046/j.1469-0705.2000.00198.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [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
OBJECTIVE This study assesses two methods used to define relatively short femur in screening for trisomy 21 and examines changes in performance of screening with gestational age. DESIGN Retrospective analysis of data on menstrual age, femur length (FL) and biparietal diameter (BPD) in 49 trisomy 21 pregnancies and 6069 normal controls. Reference ranges were derived for BPD/FL versus menstrual age and for FL versus BPD. Two methods of defining short femur (BPD/FL and observed-to-expected FL ratio) were examined for false-positive rates and detection rates for trisomy 21 at different gestational ages. RESULTS In the control group the BPD/FL ratio and its standard deviation decreased with menstrual age. Trisomy 21 was associated with a significantly higher BPD/FL ratio (P < 0.001) and the deviation increased significantly with menstrual age (P < 0.05). Eleven percent of 28 fetuses examined at 15-17 weeks had a BPD/FL above the 95th centile compared with 24% of 21 fetuses examined at 18-20 weeks (P = 0.40). The median observed-to-expected FL ratio in the control group was 1.0 throughout the gestational age range but the standard deviation decreased significantly with menstrual age (P < 0.01). Trisomy 21 was associated with a significantly reduced observed-to-expected FL ratio (P < 0.001) and the deviation increased significantly with menstrual age (P < 0.05). A fixed cut-off of 0.91 for observed-to-expected FL ratio provided a false-positive rate of 12% at 15-17 weeks compared with 6% at 18-20 weeks of gestation (P < 0.001) with detection rates of 29 and 38%, respectively (P = 0.73). CONCLUSION Irrespective of the definition used to define the condition, relatively short femur is a poor marker for trisomy 21 particularly when the assessment takes place before 18 weeks of gestation.
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Affiliation(s)
- R J Snijders
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Cedars-Sinai Medical Center Burns & Allen Research Institute, UCLA School of Medicine, Los Angeles, CA, USA
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Abstract
BACKGROUND Saline infusion sonohysterography is one of the recent refinements of ultrasonography that has the ability to enhance imaging of the uterine cavity in a safe, inexpensive and expedient manner. The technique can be difficult in women with a stenotic cervical os. This report describes a single-pass technique using chorionic villus sampling (CVS) catheters for saline infusion sonohysterography. METHOD Saline infusion sonohysterography requires the transcervical passage of a catheter, through which saline is infused. The subsequent distension of the uterine cavity enhances the ability to detect intrauterine pathology with ultrasonography. In women with cervical stenosis, a catheter can be used in place of the more conventional two-pass technique, which requires the use of a uterine sound or probe followed by a conventional catheter. EXPERIENCE We have used CVS catheters in women with cervical stenosis on 12 occasions. All have been successful and without significant discomfort to the patient. CONCLUSION The use of CVS catheters for saline infusion sonohysterography in women with cervical stenosis can alleviate the need to remove the cervical probe prior to introduction of the catheter.
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Affiliation(s)
- L D Platt
- Department of Obstetrics and Gynecology, CSMC Burns and Allen Research Institute, Cedars-Sinai Medical Center, UCLA School of Medicine, USA
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Abstract
Fifty-three patients who underwent a two-staged protocol of debridement and muscle flap coverage for chronic osteomyelitis of the tibia between 1991 and 1996 were evaluated. All patients underwent a thorough debridement of all nonviable tissue and bone at initial debridement. Multiple cultures were taken, including aerobic, anaerobic and fungal cultures from the pus, soft tissue, bone curettings and bone. All patients were treated with open wound management and dressing changes. Between 2 to 7 days, median 4 days, all patients underwent a second debridement with a complete set of identical cultures, and immediate soft tissue muscle transfer. There were 42 free vascularized and 11 local tissue transfers. The 53 patients were classified according to the Cierny-Mader classification for chronic osteomyelitis. Twenty-four patients had Stage IVA osteomyelitis, 10 patients had Stage IIIA osteomyelitis, nine patients had Stage IIIB osteomyelitis, eight patients had Stage IVB osteomyelitis, one patient had Stage IA osteomyelitis, and one patient had Stage IIB osteomyelitis. All 53 patients had positive cultures at the time of their initial debridement, and 14 of 53 (26%) had a positive culture at the time of the second debridement. Based on the results, it seems from a bacteriologic stand-point that the second debridement allows for the opportunity for redebridement and wound sterilization of organisms that still may be present.
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Affiliation(s)
- M J Patzakis
- Department of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles 90033, USA
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Greene N, Judson PN, Langowski JJ, Marchant CA. Knowledge-based expert systems for toxicity and metabolism prediction: DEREK, StAR and METEOR. SAR QSAR Environ Res 1999; 10:299-314. [PMID: 10491855 DOI: 10.1080/10629369908039182] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
It has long been recognised that the ability to predict the metabolic fate of a chemical substance and the potential toxicity of either the parent compound or its metabolites are important in novel drug design. The popularity of using computer models as an aid in this area has grown considerably in recent years. LHASA Limited has been developing knowledge-based expert systems for toxicity and metabolism prediction in collaboration with industry and regulatory authorities. These systems, DEREK, StAR and METEOR, use rules to describe the relationship between chemical structure and either toxicity in the case of DEREK and StAR, or metabolic fate in the case of METEOR. The rule refinement process for DEREK often involves assessing the predictions for a novel set of compounds and comparing them to their biological assay results as a measure of the system's performance. For example, 266 non-congeneric chemicals from the National Toxicology Program database have been processed through the DEREK mutagenicity knowledge base and the predictions compared to their Salmonella typhimurium mutagenicity data. Initially, 81 of 114 mutagens (71%) and 117 of 152 non-mutagens (77%) were correctly identified. Following further knowledge base development, the number of correctly identified mutagens has increased to 96 (84%). Further work on improving the predictive capabilities of DEREK, StAR and METEOR is in progress.
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Affiliation(s)
- N Greene
- LHASA Limited, School of Chemistry, University of Leeds, United Kingdom
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Abstract
OBJECTIVES To determine whether the use of a foot pump (intermittent pneumatic pedal compression device) in patients with excessive edema precluding surgery after acute fracture of the calcaneus leads to more rapid resolution of the edema. DESIGN Prospective randomized setting. Standard hospital in-patient ward at a Level I trauma center. PATIENTS Those patients with excessive edema precluding operative intervention upon admission after an intraarticular calcaneus fracture who signed an informed consent participated in the study. Twenty-eight patients were enrolled and completed the study: thirteen patients in the foot pump group and fifteen patients in the control group. INTERVENTION In the control group, patients had a bulky compression dressing, posterior splint, and elevation while awaiting surgery. In the study group, the patients had a foot pump applied to the foot with a posterior splint and elevation while awaiting surgery. MAIN OUTCOME MEASUREMENTS The volumetric change of the foot at twenty-four-hour intervals for up to seventy-two hours in both the control and study groups. RESULTS All thirteen patients tolerated the foot pump. The differences in the volume between Day I (baseline) and Day 2 for the foot pump and control groups were minus forty and plus seventy-six milliliters, respectively (p = 0.02). Between Days 1 and 3, the differences were minus ninety-six milliliters for the foot pump group and plus thirty-seven milliliters for the control group (p = 0.02). CONCLUSIONS A significant progressive decrease in the foot volume was noted during the first forty-eight hours after application of the foot pump in patients with excessive edema precluding operative fixation of a calcaneus fracture upon presentation. The pump was well tolerated by all the patients in the study group. Thus, we believe the pump serves as a useful adjunct in the preoperative edema resolution following these complicated fractures.
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Affiliation(s)
- D B Thordarson
- Department of Orthopaedics, University of Southern California, Los Angeles, USA
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Abstract
OBJECTIVE Technologic advances in ultrasonographic imaging have revolutionized the management of women's health care. We recently began to evaluate the clinical applications of three-dimensional ultrasonography. STUDY DESIGN This study prospectively evaluated 161 obstetric and gynecologic patients. Both two- and three-dimensional imaging data were acquired from real-time ultrasonography. Three orthogonal planes were displayed on a monitor and were used to create the rendered three-dimensional images. RESULTS To date, 201 three-dimensional ultrasonographic studies have been performed, 165 transabdominally and 36 transvaginally. Transabdominally, an average of eight acquisitions per patient were obtained. Of the clinically suspected abnormalities, 29 of 32 (91%) were confirmed by three-dimensional imaging. Three of 32 (9%) improved the diagnostic capabilities or changed the diagnosis. Of the 36 transvaginal studies, an average of four acquisitions per patient were done. Thirty (83%) of these patients had suspected abnormalities and all were confirmed. CONCLUSIONS Three-dimensional ultrasonographic imaging appears to be highly promising in the clinical setting.
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Affiliation(s)
- L D Platt
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, University of California, Los Angeles, School of Medicine, 90048, USA
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Greene N, Holtom PD, Warren CA, Ressler RL, Shepherd L, McPherson EJ, Patzakis MJ. In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos. Am J Orthop (Belle Mead NJ) 1998; 27:201-5. [PMID: 9544361] [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] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In vitro studies of antibiotic elution from polymethylmethacrylate cement comparing Simplex (Howmedica, Rutherford, NJ) with Palacos brands (Richards, Memphis, TN) have shown variable results. This study compares the elution of tobramycin and vancomycin from Simplex and Palacos beads and spacers. Six-millimeter beads and spacers were incubated in phosphate-buffered saline, and the solution was sampled and changed daily until the concentration of antibiotic fell below the minimum inhibitory concentration (MIC) for Staphylococcus aureus. In all groups, the Palacos PMMA beads and spacers showed elution at higher levels and remained above the MIC longer than did the Simplex PMMA beads. Tobramycin had superior elution to vancomycin in all groups. This in vitro study shows that Palacos PMMA has superior elution properties to Simplex PMMA in tobramycin and vancomycin beads and spacers.
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Affiliation(s)
- N Greene
- Department of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles, USA
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Affiliation(s)
- N. Greene
- LHASA UK Ltd., School of Chemistry, University of Leeds, Leeds, LS2 9JT, United Kingdom
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Dawson J, Fishbein D, Eng T, Redus M, Greene N. Diagnosis of human ehrlichiosis with the indirect fluorescent antibody test: kinetics and specificity. Ann N Y Acad Sci 1990; 590:308. [PMID: 2198831 DOI: 10.1111/j.1749-6632.1990.tb42238.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- J Dawson
- Viral and Rickettsial Zoonoses Branch, Centers for Disease Control, Atlanta, Georgia 30333
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