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PURPOSE: To characterize prevalence estimates by race, age, sex, and comorbidity (diabetes and hypertension) within the Medicare beneficiary demographic. METHODS: In this US population-based retrospective cohort analysis, the Vision and Eye Health Surveillance System was analyzed for a 100% sample of Medicare Fee-For-Service beneficiary populations of Asians and non-Hispanic Whites between 2014 and 2018. Exclusionary criteria included beneficiaries younger than 40 years. Prevalence rate ratios, defined as prevalence rate for Asians divided by prevalence rate for non-Hispanic Whites, were calculated using multivariate negative binomial regression or Pearson-scaled Poisson regression, stratified by age, sex, and comorbidity. RESULTS: A total of 21,892,200 Medicare beneficiaries fulfilled the inclusionary criteria in 2018. Of the entire cohort, 3.2% of the beneficiaries (N = 714,500) were Asian. For beneficiaries aged 40 to 64 years, Asian male (prevalence rate ratios 1.73, 95% confidence interval 1.64-1.83, P < 0.0001) and female (prevalence rate ratios 1.34, 95% confidence interval 1.28-1.41, P < 0.0001) beneficiaries had an increased prevalence rate of all age-related macular degeneration relative to non-Hispanic Whites. Significant time-wise increases in prevalence rate ratios were observed within several age groups, sexes, and comorbidities (race-time interaction coefficients P < 0.05 ). CONCLUSION: This analysis highlights increased age-related macular degeneration prevalence estimates within the Asian American demographic relative to non-Hispanic Whites. Furthermore, specific Asian subpopulations are experiencing accelerated prevalence rates over time.
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Hipertensão , Degeneração Macular , Idoso , Humanos , Masculino , Feminino , Estados Unidos/epidemiologia , Medicare , Estudos Retrospectivos , Comorbidade , Degeneração Macular/epidemiologiaRESUMO
We apply a U-Net-based convolutional neural network (NN) architecture to the problem of predictive adaptive optics (AO) for tracking and imaging fast-moving targets, such as satellites in low Earth orbit (LEO). We show that the fine-tuned NN is able to achieve an approximately 50% reduction in mean-squared wavefront error over non-predictive approaches while predicting up to eight frames into the future. These results were obtained when the NN, trained mostly on simulated data, tested its performance on 1 kHz Shack-Hartmann wavefront sensor data collected in open-loop at the Advanced Electro-Optical System facility at Haleakala Observatory while the telescope tracked a naturally illuminated piece of LEO space debris. We report, to our knowledge, the first successful test of a NN for the predictive AO application using on-sky data, as well as the first time such a network has been developed for the more stressing space tracking application.
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PURPOSE: This study aimed to investigate the incidence and risk factors of endophthalmitis after transconjunctival pars plana vitrectomy (PPV) without intraoperative subconjunctival antibiotics. DESIGN: Retrospective, consecutive case series at a single institution. METHODS: Consecutive cases of transconjunctival 25-gauge PPV without intraoperative subconjunctival antibiotics performed by three retina surgeons at a single surgical site at the Dean McGee Eye Institute from 2012 to 2018 were reviewed. RESULTS: Of 4,263 cases of PPV without intraoperative subconjunctival antibiotics, five cases (0.117%, 5/4,263) of post-PPV endophthalmitis were identified. Of these five cases, four cases (80%, 4/5) received combined cataract extraction or secondary intraocular lens implantation at the time of PPV. The incidence of endophthalmitis in isolated PPV was 0.027% (1/3,606 cases), whereas the incidence in combined PPV with anterior segment procedures was 0.608% (4/657 cases). Risk factors for endophthalmitis included diabetes mellitus, which was present in 80% of patients with endophthalmitis (4/5 cases). Causative organisms were identified in four of the five cases (80%), including Staphylococcus epidermidis (N = 3) and Propionibacterium acnes (N = 1). CONCLUSION: Performing transconjunctival PPV alone with standard preparation using povidone-iodine and postoperative topical antibiotics for 1 week without intraoperative subconjunctival antibiotics did not lead to an increase in incidence of postoperative endophthalmitis (1 per 3,606 cases).
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Endoftalmite/epidemiologia , Infecções Oculares Bacterianas/epidemiologia , Cuidados Intraoperatórios , Infecção da Ferida Cirúrgica/epidemiologia , Vitrectomia/efeitos adversos , Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Túnica Conjuntiva , Endoftalmite/prevenção & controle , Infecções Oculares Bacterianas/prevenção & controle , Feminino , Seguimentos , Humanos , Incidência , Injeções , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/prevenção & controle , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The clinical utility of genotype-guided (pharmacogenetically based) dosing of warfarin has been tested only in small clinical trials or observational studies, with equivocal results. METHODS: We randomly assigned 1015 patients to receive doses of warfarin during the first 5 days of therapy that were determined according to a dosing algorithm that included both clinical variables and genotype data or to one that included clinical variables only. All patients and clinicians were unaware of the dose of warfarin during the first 4 weeks of therapy. The primary outcome was the percentage of time that the international normalized ratio (INR) was in the therapeutic range from day 4 or 5 through day 28 of therapy. RESULTS: At 4 weeks, the mean percentage of time in the therapeutic range was 45.2% in the genotype-guided group and 45.4% in the clinically guided group (adjusted mean difference, [genotype-guided group minus clinically guided group], -0.2; 95% confidence interval, -3.4 to 3.1; P=0.91). There also was no significant between-group difference among patients with a predicted dose difference between the two algorithms of 1 mg per day or more. There was, however, a significant interaction between dosing strategy and race (P=0.003). Among black patients, the mean percentage of time in the therapeutic range was less in the genotype-guided group than in the clinically guided group. The rates of the combined outcome of any INR of 4 or more, major bleeding, or thromboembolism did not differ significantly according to dosing strategy. CONCLUSIONS: Genotype-guided dosing of warfarin did not improve anticoagulation control during the first 4 weeks of therapy. (Funded by the National Heart, Lung, and Blood Institute and others; COAG ClinicalTrials.gov number, NCT00839657.).
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Algoritmos , Anticoagulantes/administração & dosagem , Hidrocarboneto de Aril Hidroxilases/genética , Genótipo , Vitamina K Epóxido Redutases/genética , Varfarina/administração & dosagem , Adulto , Idoso , Anticoagulantes/efeitos adversos , Citocromo P-450 CYP2C9 , Método Duplo-Cego , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Humanos , Coeficiente Internacional Normatizado , Masculino , Farmacogenética , Tromboembolia , Falha de Tratamento , Varfarina/efeitos adversosRESUMO
PURPOSE: Epiretinal fibrovascular membranes (FVMs) are a hallmark of proliferative diabetic retinopathy (PDR). Surgical removal of FVMs is often indicated to treat tractional retinal detachment. This potentially informative pathological tissue is usually disposed of after surgery without further examination. We developed a method for isolating and characterizing cells derived from FVMs and correlated their expression of specific markers in culture with that in tissue. METHODS: FVMs were obtained from 11 patients with PDR during diabetic vitrectomy surgery and were analyzed with electron microscopy (EM), comparative genomic hybridization (CGH), immunohistochemistry, and/or digested with collagenase II for cell isolation and culture. Antibody arrays and enzyme-linked immunosorbent assay (ELISA) were used to profile secreted angiogenesis-related proteins in cell culture supernatants. RESULTS: EM analysis of the FVMs showed abnormal vessels composed of endothelial cells with large nuclei and plasma membrane infoldings, loosely attached perivascular cells, and stromal cells. The cellular constituents of the FVMs lacked major chromosomal aberrations as shown with CGH. Cells derived from FVMs (C-FVMs) could be isolated and maintained in culture. The C-FVMs retained the expression of markers of cell identity in primary culture, which define specific cell populations including CD31-positive, alpha-smooth muscle actin-positive (SMA), and glial fibrillary acidic protein-positive (GFAP) cells. In primary culture, secretion of angiopoietin-1 and thrombospondin-1 was significantly decreased in culture conditions that resemble a diabetic environment in SMA-positive C-FVMs compared to human retinal pericytes derived from a non-diabetic donor. CONCLUSIONS: C-FVMs obtained from individuals with PDR can be isolated, cultured, and profiled in vitro and may constitute a unique resource for the discovery of cell signaling mechanisms underlying PDR that extends beyond current animal and cell culture models.
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Retinopatia Diabética/patologia , Actinas/metabolismo , Adulto , Angiopoietina-1/metabolismo , Proliferação de Células , Separação Celular , Células Cultivadas , Hibridização Genômica Comparativa , Retinopatia Diabética/genética , Retinopatia Diabética/metabolismo , Membrana Epirretiniana/genética , Membrana Epirretiniana/metabolismo , Membrana Epirretiniana/patologia , Feminino , Proteína Glial Fibrilar Ácida/metabolismo , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Molécula-1 de Adesão Celular Endotelial a Plaquetas/metabolismoRESUMO
Optically multiplexed imaging is the process by which multiple images are overlaid on a single image surface. Uniquely encoding the discrete images allows scene reconstruction from multiplexed images via post processing. We describe a class of optical systems that can achieve high density image multiplexing through a novel division of aperture technique. Fundamental design considerations and performance attributes for this sensor architecture are discussed. A number of spatial and temporal encoding methods are presented including point spread function engineering, amplitude modulation, and image shifting. Results from a prototype five-channel sensor are presented using three different encoding methods in sparse-scene star tracking demonstration. A six-channel optically multiplexed prototype sensor is used to reconstruct imagery from information rich dense scenes through dynamic image shifting.
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Background: Educational opportunities in operating theatres are finite resources, therefore utilising them effectively is essential. Immersive video technology (IVT) may achieve this by exposing students to high-fidelity scenarios. In this study, we describe impact of IVT on student understanding of an orthopaedic procedure, barriers to surgical education, appreciation of theatre logistics and its effect on career aspirations. Methods: Purposive sampling was used to recruit UK medical undergraduates. An electronic questionnaire was developed using previous studies in the field. Half of the questionnaire was completed prior to a three-minute video describing a surgical procedure, and the second half of the questionnaire was completed after. The study design allowed researchers to collect paired qualitative data on the impact of IVT on students' subjective understanding of carpal tunnel decompression surgery and interest in surgical careers. Results: Out of 980 contacted, 207 respondents completed the 'pre' and 'post' video questionnaires. Following the video intervention, understanding of operative principles increased from 3.3 ± 0.16 (95% CI:1-7) to 6.1 ± 0.16 (95% CI:3-10, p < 0.0001). 81% of respondents reported they would feel more confident attending a carpal tunnel decompression in theatre post-video, with 60% feeling less apprehensive and 72% stating they would feel more engaged if they were shown a short educational video beforehand. Interest in pursuing a career in surgery increased from 3.9 ± 0.30 (95% CI:1-10) before watching the video to 4.2 ± 0.28 (95% CI:1-10, p < 0.0001), post-video. Conclusions: This study supports the use of immersive multimedia to enhance medical education in surgery which may stimulate student interest in surgical careers.
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Objective: The Electronic Chronic Pain Questions (eCPQ) has been developed to help healthcare providers systematically capture chronic pain data. This study evaluated the impact of using the eCPQ on patient-reported outcomes (PROs) and healthcare resource utilization (HCRU) in a primary care setting, and patient and physician perceptions regarding use of, and satisfaction with, the eCPQ. Methods: This was a prospective pragmatic study conducted at the Internal Medicine clinic within the Henry Ford Health (HFH) Detroit campus between June 2017 and April 2020. Patients (aged ≥18 years) attending the clinic for chronic pain were allocated to an Intervention Group to complete the eCPQ in addition to regular care, or a control group to receive regular care only. The Patient Health Questionnaire-2 and a Patient Global Assessment were assessed at baseline, 6-months, and 12-months study visits. HCRU data were extracted from the HFH database. Telephone qualitative interviews were conducted with randomly selected patients and physicians who used the eCPQ. Results: Two hundred patients were enrolled, 79 in each treatment group completed all 3 study visits. No significant differences (p > 0.05) were found in PROs and HCRU between the 2 groups. In qualitative interviews, physicians and patients reported the eCPQ as useful, and using the eCPQ improved patient-clinician interactions. Conclusion: Adding the eCPQ to regular care for patients with chronic pain did not significantly impact the PROs assessed in this study. However, qualitative interviews suggested that the eCPQ was a well-accepted and potentially useful tool from a patient and physician perspective. By using the eCPQ, patients were better prepared when they attended a primary care visit for their chronic pain and the quality of patient-physician communication was increased.
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PURPOSE: To evaluate whether the volume of wash out rinse after povidone iodine (PI) application for intravitreal injections (IVI) affects patients' ocular surface irritation. METHODS: This was a prospective, single-masked, randomized-controlled trial consisting of 142 subjects. A total of 51, 45, and 46 patients received 3-mL, 10-mL, and 15-mL of ocular rinse respectively. Reductions in the Ocular Surface Disease Index (OSDI) and the Standardized Patient Evaluation of Eye Dryness II (SPEED II) surveys, conducted before and at 24-72 h post-injection, were analyzed. RESULTS: There was no statistical difference in objective dry eye findings of Schirmer test (p-value = 0.788), tear break-up time (p-value = 0.403), Oxford fluorescein grade (p-value = 0.424) between the study groups prior to injections. Dry eye symptoms as measured by reductions in the OSDI and SPEEDII scores were not different between the study groups (p-value = 0.0690 and 0.6227, respectively). CONCLUSION: There is no difference in patients' ocular surface irritation between 3-mL, 10-mL, and 15-mL post injection rinse. Given the large number of IVIs performed, modification of practice patterns based on these findings could lead to significant reduction in global cost burden for IVIs.
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BACKGROUND: Thrombophilia predisposes to venous thromboembolism (VTE) because of acquired or hereditary factors. Among them, it has been suggested that gene mutations of the factor V Leiden (FVL) or prothrombin G20210A mutation (PGM) might reduce the risk of bleeding, but little data exist for patients treated using anticoagulants. OBJECTIVES: To assess whether thrombophilia is protective against bleeding. METHODS: This multicentre, multinational, prospective cohort study evaluated adults receiving long-term anticoagulants after a VTE event. We analyzed the incidence of major bleeding as the primary outcome, according to the genotype for FVL and PGM (wild-type and heterozygous/homozygous carriers). RESULTS: Of 2260 patients with genotype testing, during a median follow-up of 3 years, 106 patients experienced a major bleeding event (17 intracranial and 7 fatal). Among 439 carriers of FVL, 19 experienced major bleeding and there were no differences between any mutation vs wild-type (hazard ratio [HR], 0.89 [0.53-1.49]; p = .66). The comparison of major bleeding events between the 158 patients with any-PGM mutation (heterozygous or homozygous) vs wild-type also showed a nonstatistically significant difference with HR of 0.53 (0.19-1.43), p = .21. However, multivariate analysis demonstrated that major bleeds or clinically relevant nonmajor bleeding were statistically less likely for patients with either FVL and/or PGM compared with patients with both wild-type factor V and prothrombin genes (HR, 0.73; 95% CI = 0.55-0.97; p = .03). CONCLUSION: This study demonstrates that thrombophilia, defined as the presence of either FVL or the prothrombin G20210A mutation, is related with a lower rate of major/clinically relevant nonmajor bleeding while on anticoagulants in the extended treatment for VTE.
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Trombofilia , Tromboembolia Venosa , Adulto , Humanos , Tromboembolia Venosa/epidemiologia , Fator V/genética , Protrombina/genética , Estudos Prospectivos , Anticoagulantes , Trombofilia/genética , Mutação , Hemorragia/complicações , Fatores de RiscoRESUMO
Background: Bleeding events are common complications of oral anticoagulant drugs, including both warfarin and the direct oral anticoagulants (DOACs). Some patients have their anticoagulant changed or discontinued after experiencing a bleeding event, while others continue the same treatment. Differences in anticoagulation management between warfarin- and DOAC-treated patients following a bleeding event are unknown. Methods: Patients with non-valvular atrial fibrillation from six anticoagulation clinics taking warfarin or DOAC therapy who experienced an International Society of Thrombosis and Haemostasis (ISTH)-defined major or clinically relevant non-major (CRNM) bleeding event were identified between 2016 and 2020. The primary outcome was management of the anticoagulant following bleeding (discontinuation, change in drug class, and restarting of same drug class). DOAC- and warfarin-treated patients were propensity matched based on the individual elements of the CHA2DS2-VASc and HAS-BLED scores as well as the severity of the bleeding event. Results: Of the 509 patients on warfarin therapy and 246 on DOAC therapy who experienced a major or CRNM bleeding event, the majority of patients continued anticoagulation therapy. The majority of warfarin (231, 62.6%) and DOAC patients (201, 81.7%) restarted their previous anticoagulation. Conclusion: Following a bleeding event, most patients restarted anticoagulation therapy, most often with the same type of anticoagulant that they previously had been taking.
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Fibrilação Atrial , Acidente Vascular Cerebral , Humanos , Varfarina/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/induzido quimicamente , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Anticoagulantes , Coagulação Sanguínea , Administração Oral , Acidente Vascular Cerebral/tratamento farmacológicoRESUMO
PURPOSE: To compare spectral domain optical coherence tomography (SDOCT)-measured macular thickness, outer retinal layers architecture, and best-corrected visual acuity (BCVA) in eyes with proliferative diabetic retinopathy after pars plana vitrectomy. METHODS: In this retrospective case study, consecutive eyes operated by single surgeon were included. Retinal thickness was measured with SDOCT (Cirrus OCT; Carl Zeiss Meditec, Inc) as follows: automated central 1-mm subfield thickness (CFT), manually measured central foveal point thickness (CPT), integrity of external limiting membrane (ELM), and photoreceptor inner and outer segments (IS/OS). Three vitreoretinal-trained masked experts independently graded ELM and IS/OS layers. RESULTS: Of the 36 eyes included, 50% were those of women whose mean age was 49 years (range, 24-66 years). Mean preoperative BCVA was 20/600 (range, light perception to 20/80) and mean postoperative follow-up was 19 months (range, 4-43 months). Mean postoperative BCVA improved to 20/80 (range, counting fingers to 20/25; P < 0.0001) with mean SDOCT 1 mm CFT of 260 µm and manual CPT of 236 µm. Mean ELM integrity grade was 1.9 (range, 0-5), while the mean grade of IS/OS integrity was 2.2 (range, 0-5). The correlation coefficients (r) were 0.17 (P = 0.32) for logarithm of the minimum angle of resolution BCVA versus SDOCT automated CFT, 0.192 (P = 0.26) for BCVA versus SDOCT CPT, 0.52 (P = 0.012) for BCVA versus ELM, and 0.55 (P = 0.006) for BCVA versus IS/OS. CONCLUSION: SDOCT-measured CFT and CPT correlate weakly with BCVA, while ELM and IS/OS integrity correlates well with BCVA. Outer retinal microstructure may represent anatomically better level of postoperative visual function than retinal thickness after pars plana vitrectomy for complications of proliferative diabetic retinopathy.
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Retinopatia Diabética/complicações , Fóvea Central/patologia , Segmento Interno das Células Fotorreceptoras da Retina/patologia , Segmento Externo das Células Fotorreceptoras da Retina/patologia , Acuidade Visual/fisiologia , Vitrectomia , Adulto , Idoso , Membrana Epirretiniana/patologia , Feminino , Humanos , Pressão Intraocular , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Estudos Retrospectivos , Tomografia de Coerência Óptica , Adulto JovemRESUMO
Introduction: Postoperative endophthalmitis (POE) is a rare but devastating complication of ophthalmic surgeries. Microinvasive glaucoma surgery (MIGS) procedures have become increasingly utilized for the surgical reduction of intraocular pressure (IOP). Ab-interno canaloplasty (ABiC) is a popular MIGS procedure, but POE rates and clinical effects following ABiC have not been studied. Methods: This study conducted a retrospective review of all consecutive cases of either standalone ABiC or combined ABiC with phacoemulsification performed at a tertiary care academic referral center from 2015 to 2021. Exclusion criteria included a history of incisional glaucoma surgery, retinal surgery, or additional concurrent microinvasive glaucoma surgery (MIGS) at the time of ABiC. The rates of POE after ABiC were calculated with 95% confidence intervals (CI) based on the Clopper-Pearson exact method. Results: Of 3256 cases of ABiC, one case (0.03%, 1/3256, 95% CI: 0.00-0.17%) of post-ABiC endophthalmitis was identified. The rate of POE in standalone ABiC was 0.00% (0/1332 cases, 95% CI: 0.00-0.28%), whereas the rate in combined ABiC with phacoemulsification was 0.05% (1/1924 cases, 95% CI: 0.00-0.29%). Additionally, the rate of POE following stand-alone cataract surgery, 0.10%, 11/11,470 cases, 95% CI: 0.05-0.17%), total cataract surgeries, 0.06% (17/28,013 cases, 95% CI: 0.04-0.10%), total MIGs, excluding ABiC, surgeries, 0.08%, (3/3845 cases, 95% CI: 0.02-0.23%) portray non-inferiority of ABiC in the risk of POE. The case of ABiC-POE presented four days after surgery and required a vitreous tap with intraocular injection of antibiotics and pars plana vitrectomy. No causative organism was identified. A final 1-year follow-up revealed a corrected distance visual acuity of 20/40 and stable glaucoma. Conclusion: The rate of POE after ABiC (1 per 3256 cases) is statistically non-inferior to the reported incidence of POE after other MIGS and incisional glaucoma surgeries.
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BACKGROUND: Differences in clinical outcomes following a temporary interruption of warfarin or a direct oral anticoagulant (DOAC) for a surgical procedure are not well described. Differences in patient characteristics from practice-based cohorts have not typically been accounted for in prior analyses. AIM: To describe risk-adjusted differences in postoperative outcomes following an interruption of warfarin vs DOACs. METHODS: Patients receiving care at six anticoagulation clinics participating in the Michigan Anticoagulation Quality Improvement Initiative were included if they had at least one oral anticoagulant interruption for a procedure. Inverse probability of treatment weighting (IPTW) was used to balance baseline differences between the warfarin cohort and DOAC cohort. Bleeding and thromboembolic events within 30 days following the procedure were compared between the IPTW cohorts using the Poisson distribution test. RESULTS: A total of 525 DOAC patients were matched with 1323 warfarin patients, of which 923 were nonbridged warfarin patients and 400 were bridged warfarin patients. The occurrence of postoperative minor bleeding (10.8% vs. 4.7%, p < .001), major bleeding (2.9% vs. 1.1%, p = .01) and clinically relevant nonmajor bleeding (CRNMB) (6.5% vs. 3.0%, p = .002) was greater in the DOAC cohort compared with the nonbridged warfarin cohort. The rates of postoperative bleeding outcomes were similar between the DOAC and the bridged warfarin cohorts. CONCLUSION: Perioperative interruption of DOACs, compared with warfarin without bridging, is associated with a higher incidence of 30-day minor bleeds, major bleeds, and CRNMBs. Further research investigating the perioperative outcomes of these two classes of anticoagulants is warranted.
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Fibrilação Atrial , Varfarina , Humanos , Varfarina/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Estudos Retrospectivos , Anticoagulantes/efeitos adversos , Hemorragia Pós-Operatória/induzido quimicamente , Administração OralRESUMO
Patients' international normalized ratios (INRs) often fall slightly out of range. In these cases, the American College of Chest Physicians (ACCP) guidelines suggest maintaining the current warfarin dose and retesting the INR within the following 2 weeks (watchful waiting). We sought to determine whether watchful waiting or dose changes for slightly out-of-range INRs is more effective in obtaining in-range INRs at follow-up. INRs and management strategies of warfarin-treated patients within the Michigan Anticoagulation Quality Improvement Initiative registry were analyzed. Management strategies included watchful waiting or dose changes. INRs slightly out of range (target range 2.0-3.0) and their associated management were identified. Multilevel mixed-effects logistic regression was used to estimate the probability of the next INR being in range, adjusted for clustering due to multiple out-of-range INRs per patient. A total of 45 351 slightly out-of-range INRs (ranging 1.50-1.99 and 3.01-3.49) from 8288 patients were identified. The next INR was slightly less likely to be in range with watchful waiting than with a dose change (predicted probabilities 58.9% vs 60.0%, P = 0.024). Although a significant statistical difference was detected in the probabilities of the next INR being back in range when managed by a dose change compared with watchful waiting following a slightly out-of-range INR, the magnitude of the difference was small and unlikely to represent clinical importance. Our study supports the current guideline recommendations for watchful waiting in cases of slightly out-of-range INRs values.
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Anticoagulantes , Varfarina , Anticoagulantes/uso terapêutico , Humanos , Coeficiente Internacional Normatizado , Varfarina/uso terapêutico , Conduta ExpectanteRESUMO
PURPOSE: To evaluate the utility of dissolvable collagen punctal plugs (CPP) in reducing ocular surface irritation after intravitreal injections (IVI). METHODS: Sixty-four subjects in the experimental group received CPP after intravitreal injections. Sixty-two controls did not receive CPP. Reductions in the Ocular Surface Disease Index© (OSDI) and Standardized Patient Evaluation of Eye Dryness II (SPEED II) scores were analysed. RESULTS: Dry eye symptoms, as measured by reductions from the pre- to post-injection OSDI (p = 0.137) and SPEED II (p = 0.381) scores, did not significantly differ between the two groups. In sub-group analysis, patients with objective findings of dry eyes had significant improvement in their symptoms (p = 0.046) with CPP. The effect of CPP is not significant in those without dry eyes (p = 0.27). CONCLUSION: CPPs were not effective in reducing post-injection ocular irritation in patients with no or only mild dry eye symptoms. CPPs improved patients' post-injection comfort levels in those who had moderate-to-severe symptoms and objective findings of dry eye. Though costly CPP could be considered in selective patients. A standardized eye rinse could be a simple, efficacious, and cost-effective way to reduce post-injection ocular irritation; however, more studies are needed.
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Síndromes do Olho Seco , Plug Lacrimal , Síndromes do Olho Seco/tratamento farmacológico , Olho , Humanos , Injeções Intravítreas , Povidona-Iodo/uso terapêutico , LágrimasRESUMO
Hydroxychloroquine (HCQ) is an anti-malarial drug but also widely used to treat autoimmune diseases like arthritis and lupus. Although there have been multiple reports of the adverse effect of prolonged HCQ usage on the outer retina, leading to bull's-eye maculopathy, the effect of HCQ toxicity on the inner retina as well as on overall visual functions has not been explored in detail. Furthermore, lack of an established animal model of HCQ toxicity hinders our understanding of the underlying molecular mechanisms. Here, using a small clinical study, we confirmed the effect of HCQ toxicity on the inner retina, in particular the reduction in central inner retinal thickness, and established a mouse model of chronic HCQ toxicity that recapitulates the effects observed in human retina. Using the mouse model, we demonstrated that chronic HCQ toxicity results in loss of inner retinal neurons and retinal ganglion cells (RGC) and compromises visual functions. We further established that HCQ treatment prevents autophagosome-lysosome fusion and alters the sphingolipid homeostasis in mouse retina. Our results affirm the notion that HCQ treatment causes early damage to the inner retina and affects visual functions before leading to characteristic toxicity in the macular region of the outer retina, 'bull's-eye maculopathy.' We also provide insights into the underlying molecular mechanisms of HCQ retinal toxicity that may involve autophagy-lysosomal defects and alterations in sphingolipid metabolism.
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Antirreumáticos , Degeneração Macular , Doenças Retinianas , Animais , Antirreumáticos/efeitos adversos , Autofagossomos , Hidroxicloroquina/efeitos adversos , Lisossomos , Camundongos , Retina , Doenças Retinianas/induzido quimicamente , Doenças Retinianas/tratamento farmacológico , Esfingolipídeos , Tomografia de Coerência Óptica/métodosRESUMO
Background For more than a decade, guidelines have recommended a limited 3 months of anticoagulation for the treatment of provoked venous thromboembolism (VTE). How closely real-world practice follows guideline recommendations is not well described. Methods and Results In our multicenter, retrospective cohort study, we evaluated trends in anticoagulation duration for patients enrolled in the MAQI2 (Michigan Anticoagulation Quality Improvement Initiative) registry who were receiving anticoagulation for a provoked VTE. The MAQI2 registry comprises 6 centers in Michigan that manage patients' long-term anticoagulation. We identified 474 patients on warfarin and 302 patients on direct oral anticoagulants who were receiving anticoagulation for a primary indication of provoked VTE between 2008 and 2020. Using a predefined threshold of 120 days (3 months plus a buffer period), predictors of extended anticoagulant use were identified using multivariable logistic regression. Most patients received >120 days of anticoagulation, regardless of which medication was used. The median (25th-75th percentile) length of treatment for patients taking warfarin was 142 (91-234) days and for direct oral anticoagulants was 180 (101-360) days. Recurrent VTE (odds ratio [OR], 2.75 [95% CI, 1.67-4.53]), history of myocardial infarction (OR, 3.92 [95% CI, 1.32-11.7]), and direct oral anticoagulant rather than warfarin use (OR, 2.22 [95% CI, 1.59-3.08]) were independently associated with prolonged anticoagulation. Conclusions In our cohort of patients with provoked VTE, most patients received anticoagulation for longer than the guideline-recommended 3 months. This demonstrates a potential opportunity to improve care delivery and reduce anticoagulant-associated bleeding risk.
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Tromboembolia Venosa , Humanos , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/induzido quimicamente , Varfarina , Estudos Retrospectivos , Anticoagulantes/uso terapêutico , Fatores de RiscoRESUMO
Importance: For some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes. Objective: To assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin. Design, Setting, and Participants: This pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021. Intervention: Primary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician. Main Outcomes and Measures: Outcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time. Results: A total of 6738 patients treated with warfarin (3160 men [46.9%]; mean [SD] age, 62.8 [16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P < .001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P = .001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P = .03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P = .34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P = .02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P = .001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P = .04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P = .36 for change in slope before and after 24 months before the intervention). Conclusions and Relevance: This quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic-based aspirin deimplementation intervention can improve guideline-concordant aspirin use.
Assuntos
Fibrilação Atrial , Tromboembolia Venosa , Adulto , Anticoagulantes/efeitos adversos , Aspirina , Fibrilação Atrial/tratamento farmacológico , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Varfarina/efeitos adversosRESUMO
No clinical prediction model has been specifically developed or validated to identify patients with unprovoked venous thromboembolism (VTE) who are at high risk of major bleeding during extended anticoagulation. In a prospective multinational cohort study of patients with unprovoked VTE receiving extended anticoagulation after completing ≥3 months of initial treatment, we derived a new clinical prediction model using a multivariable Cox regression model based on 22 prespecified candidate predictors for the primary outcome of major bleeding. This model was then compared with modified versions of 5 existing clinical scores. A total of 118 major bleeding events occurred in 2516 patients (annual risk, 1.7%; 95% confidence interval [CI], 1.4-2.1). The incidences of major bleeding events per 100 person-years in high-risk and non-high-risk patients, respectively, were 3.9 (95% CI, 3.0-5.1) and 1.1 (0.8-1.4) using the newly derived creatinine, hemoglobin, age, and use of antiplatelet agent (CHAP) model; 3.3 (2.6-4.1) and 1.0 (0.7-1.3) using modified ACCP score, 5.3 (0.6-19.2) and 1.7 (1.4-2.0) using modified RIETE score, 3.1 (2.3-3.9) and 1.1 (0.9-1.5) using modified VTE-BLEED score, 5.2 (3.3-7.8) and 1.5 (1.2-1.8) using modified HAS-BLED score, and 4.8 (1.3-12.4) and 1.7 (1.4-2.0) using modified outpatient bleeding index score. Modified versions of the ACCP, VTE-BLEED, and HAS-BLED scores help identify patients with unprovoked VTE who are at high risk of major bleeding and should be considered for discontinuation of anticoagulation after 3 to 6 months of initial treatment. The CHAP model may further improve estimation of bleeding risk by using continuous predictor variables, but external validation is required before its implementation in clinical practice.