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Owen Selden

Family Pharmaceuticals – The Ethics of Family Pharmacists

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Family Pharmaceuticals – The Ethics of Family Pharmacists

Many of us have encountered a friend who shares a “medical hack” when they reference that distant family member –– an uncle or a cousin –– who can prescribe them whichever medication they choose. That friend may rant or rave that whenever they are sick, “amoxicillin” or any sort of antibiotic is their panacea which cures even the most stringent of colds. However, I do not utilize the word colds lightly as that is a viral infection and many times, these medications are not utilized with the backing of the rigorous diagnostic process that a clinician performs as part of patient care. Rx has now effectively become through the family tree; instead of having the protective gutter guards that prevent one from unnecessarily taking medication, access has been expanded. This has both beneficial and detrimental impact on patient care and therefore has serious ethical implications. These implications cannot be understood without laying a simple foundation: who in the medical system is eligible to prescribe and can be deemed a “prescriber,” and what legislative stipulations and ethical obligations govern that ability? Furthermore, with the understanding of prescriptive authority, an ethical scenario, and then some legislative context, one can understand that the ethical guidelines that have been established are clear, but need additional reinforcements. 

Prescriptive authority is an area of healthcare that has seen accelerated changes within recent years through the growth of physician assistants (PAs) and nurse practitioners (NPs) which have a scope of practice that has expanded and evolved over time [1]. Physicians with the highest degree of prescriptive authority are those with a Doctor of Medicine (MD) or a Doctor of Osteopathic Medicine (DO) designation as they are able to prescribe medications, including controlled substances which include medications such as opioids, stimulants, depressants, hallucinogens, and anabolic steroids [1]. Furthermore, with a Drug Enforcement Agency (DEA) license, these physicians are able to prescribe Schedule II to V medications, which are narcotics and controlled substances. The advent of the first physician assistants class formed in 1965 saw the advent of a novel healthcare professional seeking to fill the gap left by the shortage of physicians. Although state law varies, these healthcare professionals lack complete autonomy as they must be overseen by a physician. Furthermore, the advent of nurse practitioners were seen to deal with the lack of access to pediatric care [1]. Unlike PAs, NPs have greater prescriptive privileges in many states and do not require physician supervision as they are even allowed to prescribe controlled substances. With the increase in PA and NP professionals in recent years, the progressive increase in prescriptive authority has led to changing state laws to increase their autonomy in order to improve healthcare accessibility [1]. 

Having established those who are able to prescribe medication, diving into a simple ethical scenario is foundational for understanding the ethics of family pharmacists –– if your spouse or partner got a skin infection and needed an antibiotic, is it ethical for you to prescribe that medication to them [2]? There are serious ethical implications and under certain circumstances, it can be argued that it is ethically permissible to treat one’s family members, but in other situations it is not appropriate. Defining the ethical boundary here is incredibly important as it will come with context and provides a framework for caregivers. In emergency situations, such as a cardiopulmonary resuscitation, it is clear that a physician should treat their immediate family member without question as the emergency situation would require them to act to save a life [2]. However, this is not the situation that most ethical concerns would arise; those matters occur when symptoms are nonemergent, when a disease is out of the scope of one’s clinical skills allowing for improper diagnosis. 

The Council on Ethical and Judicial Affairs of the American Medical Association determined that if the condition is only a short-term and minor problem, such as a skin infection, it is permissible for a physician to treat family members. The ethical boundary here is that the condition must be short-term, whereas long-term treatments are not permissible [3]. Furthermore, in their analysis of 400 medical staff physicians, they found that 99% of physicians had received requests from family members for medical advice or therapy with 83% of respondents reporting that they had prescribed medication for a family member, and 72% reporting  that they had conducted a physical examination. This evidence shows that physicians are utilized by their families as sources of “discounted” medical care. The serious implication and problem with treating family members is the potential for personal relationships to impact treatment and determination of the optimal course of therapy for a patient to undergo [2]. In Drs. Korenman and Mramstedt’s article published in the The Western Journal of Medicine, they argued that several conditions must be met for physicians to prescribe to family members: the ailment is within the physician’s expertise, the physician should not accept any limitations on access to patient’s medical records, physicians should know enough about the method of therapy to feel comfortable with it suse, and follow-up is essential for the treatment to be successful.

These guidelines are solid, but they do not provide enough specificity into the core issue of family pharmacists –– the implication that prescriptions can be made for unnecessary or improperly used medication [4]. In some states, it is completely illegal and rightfully so for physicians to prescribe controlled substances to themselves or other immediately family members, such as North Carolina Rules 21 NCAC 32 B.1001, 32S.0212, and 32M.0109; however, the prescription medications are still legal to be prescribed to family members [5]. Many of these prescriptions can be made for patients who are receiving treatment for conditions they may not have been properly diagnosed. For instance, the friend who has a viral infection or a cold but claims that azithromycin is a panacea for all of their problems. A family member may give them an “Rx” for this medication to treat a condition which it will not even remotely improve and as a result, that patient who is effectively self-prescribing is causing greater damage and the potential generation of antibiotic resistant bacteria [6]. 

The ethics here are clear, but the legislation is not legally binding enough. The ethical scenarios essentially establish that patients must be in non-life threatening scenarios within a physician’s scope of reference and to where all diagnostic ability can be used. These situations are often not the contexts in which these physicians are prescribing medications, and many times these guidelines established by the American Medical Association are not adhered to [7]. The ethics here are clear, but the legislation fails to protect patients, even when they believe that a family member could be protecting them. 

Greater legislative constraints must be placed on “family pharmacists.” That is where there are largely restrictions on “controlled substances” for prescribers, many other prescription medications can have harmful effects beyond just addiction which is the reason for the controlled element of many of these medications [8]. Furthermore, there needs to be some legal protection in place for physicians. In order to prescribe to family members, they must go through higher levels of approval, such as an ethics board where documentation of treating immediate friends and family members can be reviewed following treatment. The proposed regulatory process is not a slowing down of treatment, but that all of the diagnostic processes with a justification of the treatment plan must be defended under an annual review. Failure to disclose these treatments should potentially result in loss of licensure. 

This may potentially seem strict and stringent to many, but I feel that given the history of the opioid epidemic and the potential negative effects of unmitigated family pharmacies that there must be additional safeguards in place. The system that I have proposed is online, the specificity of it is broad, but its intention is multi-pronged: regulate family pharmacies, protect patients, and maintain efficiency. I do not want this potential legislative action to hinder the ability of patients to receive care, but there must be a higher level of scrutiny placed upon these situations in order to guarantee that physicians are marking ethical and accurate decisions as bias is inherent in these treatment plans. I believe that the access to medicine provided through these close connections to providers can be of great benefit to patients, but that does not mean that it cannot also be of great harm. To mitigate and minimize this harm is an obligation on part of governments who are aware of these backdoor prescriptions. 


Sources: 

1) Zhang P, Patel P. Practitioners And Prescriptive Authority. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574557/

2) Korenman, S. G., & Bramstedt, K. A. (2000). Your spouse/partner gets a skin infection and needs antibiotics: is it ethical for you to prescribe for them? Yes: it is ethical to treat short-term, minor problems. The Western journal of medicine, 173(6), 364. https://doi.org/10.1136/ewjm.173.6.364 

3) La Puma J, Stocking CB, La Voie D, Darling CA. When physicians treat their own families: practices in a community hospital. N Engl J Med 1991;325: 1290-1294. 

4) Latessa, R., & Ray, L. (2005). Should you treat yourself, family or friends?. Family practice management, 12(3), 41–44. 

5) Resources & Information. 2.2.3: Self-Treatment and Treatment of Family Members. (n.d.). https://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/self-treatment_and_treatment_of_family_members 

6) What happens when you write rx’s for relatives | mdlinx. (n.d.). https://www.mdlinx.com/article/what-happens-when-you-write-rx-s-for-relatives/lfc-3094  

7) Virtual Mentor. 2012;14(5):396-397. doi: 10.1001/virtualmentor.2012.14.5.coet1-1205. 

8) The controlled substances act. DEA. (n.d.). https://www.dea.gov/drug-information/csa  

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Ethics of Transparency in Dining Halls: Choice-Prohibitive Situations

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Ethics of Transparency in Dining Halls: Choice-Prohibitive Situations

How often do we consider that the food currently on our plates was the product of rigorous genetic and scientific experimentation? The food is, in a sense, designer. We could be consuming food that was designed, selected, and tested to perfection in the same way that any other product made available to us is. Typically, eating ‘natural’ ingredients implies eating freshly grown food from farmer’s markets or ‘organic’ producers. Consuming ‘fresh’ food is marketed throughout the University of Virginia’s dining halls – but is the food that we consume truly organic, or is it a designer product? 

Genetically Modified Organisms (or GMOs) are defined by the U.S. Department of Agriculture as “an animal, plant, or microbe whose DNA has been altered using genetic engineering techniques” [1]. For thousands of years, human beings have utilized selective breeding methods to select for particular phenotypes, so in a sense we have been genetically modifying for thousands of years already [2]. For example, the reason that bananas are yellow is due to genetic modification through years of artificial selection; initially bananas were green and red. Recently, selective breeding has been augmented by modern biotechnology which grants scientists the capability to directly modify the genetic code. Both the crops and animals that produce the food purchased in our local groceries stores – subsequently served in school meals – potentially bear the signature of purposeful genetic adaptation. 

Genetic alteration has allowed for massive advancement in food production, helping increase yields and production of food within the confines of the agricultural space currently available to us. For instance, many genetically modified plants resistant to herbicides allow for greater yields of crops. This is an important innovation, especially with a growing population and already present issues with food insecurity. In the United States, 10.2% of households are food-insecure, 6.4% are households with low food security, and 3.8% of households have very low food security [3]. Genetically Modified Organisms provide a solution that takes us one step closer towards ending food insecurity, as well as provides a potential and feasible solution to solving world hunger. 

Despite the benefits, there are still fears and trepidation as people question the safety of genetically modified food. There are legitimate concerns of the potential allergenic properties of genetically modified organisms, as well as the transfer effects of antibiotic resistance whereby modified organisms could pass resistance to bacteria. Ultimately, there are potentially negative consequences for human health that “could result from differences in nutritional content, allergic response, or undesired side effects such as toxicity, organ damage, or gene transfer” [4]. Many of these fears can be quelled by current science which affirms that genetically modified organisms are safe. However, genetically modified organisms, specifically those that are experimentally-derived, have not been incorporated into diets for long enough to have complete certainty as to potential ramifications on health in the future. Furthermore, many laws and regulations which are designed to govern the world of biotechnology are too archaic and outdated to successfully monitor and control the safety of the food being manufactured. There is a desire and push for greater research and labeling to present the dangers of genetically modified foods to consumers when they are purchasing food in grocery stores. Providing people with that information, I will argue later, is incumbent upon the manufacturer, the Food and Drug Administrator, grocery stores, food distributors, and retailers who utilize those genetic technologies.

The dining halls of the University of Virginia have monopolized the food market filled with students of all years, majors, and dietary preferences without providing full transparency. At the University of Virginia, first-year students are required and expected to purchase an ‘all inclusive dining plan,’ which includes unlimited swipes into dining halls each day. This plan is incredibly expensive and, because first-years are also not allowed to have cars on grounds and are therefore unable to drive to grocery stores, they are left without the option to dine elsewhere. This leaves them without the option to choose whether or not they would like to eat in the dining hall because it is essentially the only on-campus dining option. Thus, the University has effectively monopolized the market and ended any notion of “choice” that students may have in food choice when living on grounds their first-year. 

Nutritional information about the meals being served in the dining halls is available, but there is no information provided as to whether the foods are genetically modified or not. This prevents students from making informed decisions about whether or not they would like to eat genetically modified food. If a student is vegetarian and does not want to eat meat, they are provided with the information necessary to eat within that chosen dietary preference. While if a student did not want to eat genetically modified food, that information is not given to them in order to make an informed decision about the food they would like to consume. In public health, it is a common tactic when approaching issues with food or dietary habits to treat “food as medicine” [5]. Treating food as medicine and viewing people as patients, one can consider the ethical implications of not providing information to students as they make uninformed decisions about what food they would like to eat. 

When treating food as medicine and those who eat in dining halls as patients, lack of informed consent is clearly displayed. If a patient is involuntarily given a medicine, the patient is assumed to have the right to choose treatment – and if that is not given, then the patient will be informed of the implications of the treatment being received [6]. These are basic tenets of informed consent and are not made available to the ‘patients’ in the case of the dining hall, as students are not fully informed of the nature and background of the food being made available to them. 

This is an issue of transparency – UVA Dine (University of Virginia’s dining hall company) has an ethical obligation to inform students if they do not provide them with a choice. The UVA Dine’s website provides no information as to whether or not genetically modified organisms are used [7]. UVA’s distributors include 4PFoods which is a certified organic producer, which means they can’t use any synthetic pesticides, chemical fertilizers or GMOs [8]. However, other distributors like  Produce Source Partners and Cavalier Produce have no information regarding their use of  genetically modified organisms in their food on their websites [9,10]. Students are owed transparency and greater information regarding the use of genetically modified food in order for them to make informed dietary decisions. Furthermore, in the situation in which you treat food as medicine, you are not providing students with the information allowing for informed consent. UVA Dine is not upholding its ethical obligation to inform. 

I believe that Genetically Modified Organisms should be utilized in dining halls, but information and transparency must be given. Through a utilitarian perspective, genetically modified foods allow for the great amount of healthy food to be offered at a low price. The dining halls would advertise themselves as organic, if they were not using genetically modified organisms [11, 12]. UVA Dine says that they prioritize organic food, but this does not mean that all of their food is organic. I believe that in a situation like this, in which students are devoid of choice, they must be given all relevant information. Having a lack of information and choice creates a situation in which students who dine at UVA are unable to make meaningful informed decisions. Genetically Modified foods have a valuable role to play in the fight against world hunger and food insecurity, but they must come with warnings and transparency––people have a right to know. 

Sources: 

  1. “Agricultural Biotechnology Glossary.” USDA, https://www.usda.gov/topics/biotechnology/biotechnology-glossary. 

  2. “Genetically Modified Organisms.” National Geographic Society, https://education.nationalgeographic.org/resource/genetically-modified-organisms. 

  3. “Key Statistics & Graphics.” USDA ERS - Key Statistics & Graphics, https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/key-statistics-graphics/. 

  4. SITNFlash. “Will Gmos Hurt My Body? the Public's Concerns and How Scientists Have Addressed Them.” Science in the News, 17 Jan. 2021, https://sitn.hms.harvard.edu/flash/2015/will-gmos-hurt-my-body/#:~:text=One%20specific%20concern%20is%20the,organ%20damage%2C%20or%20gene%20transfer 

  5. Graber, Eric. “Food as Medicine.” American Society for Nutrition, 24 Feb. 2022, https://nutrition.org/food-as-medicine/ 

  6. Keatley, K L. “Controversy over genetically modified organisms: the governing laws and regulations.” Quality assurance (San Diego, Calif.) vol. 8,1 (2000): 33-6. doi:10.1080/105294100753209174 

  7. Davies, Benjamin. “Responsibility and the limits of patient choice.” Bioethics vol. 34,5 (2020): 459-466. doi:10.1111/bioe.12693 

  8. “What We Are Doing On Grounds.” UVA Dine, https://virginia.campusdish.com/en/Sustainability/WhatWeAreDoing#:~:text=When%20local%20items%20are%20used,ingredients%20to%20our%20dining%20locations.

  9. https://4pfoods.com/posts/what-do-all-those-labels-stand-for/#:~:text=At%204P%20Foods%20we%20get,%2C%20antibiotics%2C%20chemicals%20or%20vaccines

  10.  “Read Food Labels like A pro: What You Need to Know.” 4P Foods, https://4pfoods.com/posts/what-do-all-those-labels-stand-for/#:~:text=At%204P%20Foods%20we%20get,%2C%20antibiotics%2C%20chemicals%20or%20vaccines.  

  11. “Cavalier Produce.” Cavalier Produce, https://www.cavalierproduce.com/.  

  12. McEvoy, Posted by Miles. “Organic 101: Can Gmos Be Used in Organic Products?” USDA, 21 Feb. 2017, https://www.usda.gov/media/blog/2013/05/17/organic-101-can-gmos-be-used-organic-products#:~:text=The%20use%20of%20genetic%20engineering,t%20use%20any%20GMO%20ingredients.  

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Retina-Specialized Clinical Care: Ethics of Sustainment

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Retina-Specialized Clinical Care: Ethics of Sustainment

This Winter Break, I worked for a Vitreoretinal Surgeon in Charleston, South Carolina as an Ophthalmic Technician, trained on taking Visual Acuity Exams, Optical Coherence Tomagraphs (OCTs), Fundoscopic Examinations (Fundus), and Fluorescein Angiographs (FA). The patient population that I worked with had significantly high levels of diabetes, a disease that requires constant and ongoing medical care to sustain many physiological functions, in this case, sight. Before I begin, I want to provide a disclaimer that I am not an expert in Diabetes or any of the conditions discussed and have explained these conditions to the best of my ability. Furthermore, the context on these diseases will provide background for the argument that I am going to make concerning the ethics of sustainment, a phrase that I have coined referring to the ethical implications of continuing to provide medical care when non-life-threatening conditions are being stabilized or sustained, without hope of improvement.

Diabetes is one of the least understood, most stigmatized, and pervasive diseases present in our society today. The reality is that 34.6 million Americans are living with diabetes, but only 28.7 million people of all ages––8.7% of the population––are diagnosed with either Type I or Type II [1]. According to the Centers for Disease Control, “for both men and women, prevalence of diagnosed diabetes was highest among American Indians and Alaska Natives (14.5%), followed by non-Hispanic Blacks (12.1%), people of Hispanic origin (11.8%), non-Hispanic Asians (9.5%) and non-Hispanic Whites (7.4%)” [1]. Type I Diabetes is an autoimmune disease in which the immune system of a patient who presents with Type I attacks the beta-cells of the pancreas and the patient’s pancreas stops producing insulin, therefore this type of diabetes is called Insulin-Dependent Diabetes [2]. Typically patients with Type I Diabetes will be diagnosed earlier in childhood. This disease has a genetic component, but it does not occur from birth. It is believed that there is a viral origin that causes Type I Diabetes [3]. Type II Diabetes is the form of diabetes that is closely associated with obesity and weight with the majority of people with diabetes, roughly 90%, having Type II Diabetes [4]. Type II Diabetes occurs when patients cannot produce enough insulin to regulate the sugar (glucose) present in their blood or when patients have issues with insulin’s cellular function, as it does not adequately stimulate glucose uptake. 

In the patients that I worked with at Charleston Retina Consultants, I observed the clinical manifestation of diabetes, as well as its prevalence and lack of regulation. As part of the screening process, I had to intake patients and ask them what their blood sugar was and only one out of ten of them would know their hemoglobin A1C, which “measures your average blood sugar levels over the past 3 months.” Hemoglobin A1C is a common way to test and diagnose prediabetes and diabetes. For diabetics, blood sugar must be closely regulated because if it is too high or too low there could be serious clinical complications, including nephropathy, neuropathy, retinopathy, cardiovascular issues, diabetic coma, diabetic ketoacidosis, and so on [6]. The condition that we were treating through vitreoretinal injections was retinopathy, which manifests clinically in different forms. 

I saw this first-hand when I performed Optical Coherence Tomagraphs on patients, which is a scan of a cross-section of the retina, which allows ophthalmologists to measure the thickness and help with diagnosing retinal diseases [7]. I could see Diabetic Macular Edema––the most common cause of retinal complications that we treated––in the abnormal swelling in the macula that can affect the fovea on the scans that I was taking [8]. Of the patients we saw in a day experiencing retinal complications, a high percentage of them had diabetes. The disease causes abnormal blood vessel growth in the retina leading to vision impairment. This lifelong struggle leads to constant doctor’s appointments, where patients are poked, prodded, injected, and moved in and out of doctors' offices is, to put it lightly, not fun. For patients, they dread the doctors' office because it seems to be a place filled solely with negatives––bad news, suggestions to change lifestyle, fatphobia, and unpleasant experiences. 

In my experience, I would prepare patients for injections which they had been receiving monthly for years. These patients would be on their fortieth, sixtieth, and seventy-eighth injection, which involves them coming into clinic and getting their eyes dilated, numbed, repeatedly examined with bright lights, and then numbed again with lidocaine, followed by injections which can be painful upon injection, as well as cause pain in patients for the next couple of days. Furthermore, each of these visits prevent patients from being able to go to work, take care of their children, and provide a constant burden upon them. In many of these situations, these injections improve vision significantly and patients will stop injections once their conditions, whether macular edema or another retinal condition, however, the ethical scenario of sustainment applies to patients who receive injections to preserve vision without the hope of significant improvement [10]. 

This preservation or sustainment as opposed to improvement places this form of treatment in a category which is separate and distinct from care which improves conditions. To place this in the traditional principles of ethical and clinical categories of beneficence, nonmaleficence, autonomy, and justice [11]. The ethical scenario in this situation is one of beneficence––does the patient benefit enough from the maintenance of vision as opposed to the financial and physical toll of receiving indefinite monthly injections? This scenario highlights the importance of considering that health may not be the only factor that should be considered when providing care to patients. Furthermore, in this situation, patients have received injections for such an extended period without hope of improvement, yet still have vision that can be classified as significantly impaired. 

This is where I believe the ethics of sustainment should be applied in clinical practice that we should consider care to sustain a non-life threatening condition, such as macular edema, in a different bioethical context. Sustainment should be defined as treatment or elective procedures that are maintaining current conditions without the likelihood of significant improvement. For instance, a patient who has received sixty injections to preserve already sub-optimal vision to prevent blindness. Sustaining this condition is not only expensive but incredibly stressful as patients must attend appointments on a monthly basis which prevents them from earning income and pursuing other opportunities. 

I got to chat with one patient about the trip she planned to go to Australia. I shared with her my love of kangaroos and excitement for her to experience all that Australia had to offer. As we chatted, she opened up to me about this being her last “hoorah” so to speak––that she and her husband were both terminally ill and their life was short. I expressed my sympathy, and wished her the best on her trip––I talked about how important I thought it could be for her to spend the time she had left living life to its fullest. This patient was terminally ill and receiving painful and taxing injections to preserve her vision in the last years of her life. 

This is the prime ethical scenario in which I believe that the ethics of sustainment must be applied, a patient who has no hope of improved vision and suffers other conditions or circumstances which complicate treatment, should have their care decided in a separate field of consideration. I believe that when you are sustaining and not improving in specific non-life threatening situations that it is incumbent upon providers to prioritize the wellbeing of the patient, which may not always be a biological or physiological improvement. Therefore, in a situation of sustainment, you need to consider multiple factors including financial and personal well-being. This concept applies neither to life-saving or highly-likelihood of improvement procedures, only procedures that sustain a condition. The notion of considering the ethics of sustainment is a piece that clinical bioethics doesn’t concentrate on as it's largely concerned with life-or-death situations. However, a significant amount of clinical care doesn’t fall into this category and thus, other ways of thinking such as this must be explored and considered in greater depth. 


Sources: 

  1. Centers for Disease Control and Prevention. (2022, September 30). Prevalence of diagnosed diabetes. Centers for Disease Control and Prevention. Retrieved January 20, 2023, from https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-diabetes.html 

  2. Mayo Foundation for Medical Education and Research. (2022, July 7). Type 1 diabetes. Mayo Clinic. Retrieved January 20, 2023, from https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011 

  3. Filippi, C. M., & von Herrath, M. G. (2008). Viral trigger for type 1 diabetes: pros and cons. Diabetes, 57(11), 2863–2871. https://doi.org/10.2337/db07-1023

  4. Mayo Foundation for Medical Education and Research. (2022, November 19). Type 2 diabetes. Mayo Clinic. Retrieved January 20, 2023, from https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193 

  5. Centers for Disease Control and Prevention. (2022, September 30). All about your A1C. Centers for Disease Control and Prevention. Retrieved January 20, 2023, from https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html 

  6. Mayo Foundation for Medical Education and Research. (2022, August 11). Diabetic coma. Mayo Clinic. Retrieved January 20, 2023, from https://www.mayoclinic.org/diseases-conditions/diabetic-coma/symptoms-causes/syc-20371475#:~:text=Blood%20sugar%20that's%20either%20too,toxic%20acids%20known%20as%20ketones. 

  7. Turbert, D. (2022, May 26). What is optical coherence tomography? American Academy of Ophthalmology. Retrieved January 20, 2023, from https://www.aao.org/eye-health/treatments/what-is-optical-coherence-tomography 

  8. Diabetic macular edema (DME). Prevent Blindness. (2022, October 12). Retrieved January 20, 2023, from https://preventblindness.org/diabetic-macular-edema-dme/ 

  9. The American Society of Retina Specialists. (n.d.). Intravitreal injections. Intravitreal Injections - Patients - The American Society of Retina Specialists. Retrieved January 20, 2023, from https://www.asrs.org/patients/retinal-diseases/33/intravitreal-injections 

  10. Nizawa, T., Kitahashi, M., Baba, T., Iwase, T., Kubota-Taniai, M., Hattori, Y., Shiko, Y., Kawasaki, Y., Iwase, T., Sato, T., Ogawa, S., Sugawara, T., & Yamamoto, S. (2021). Improvements of Retinal Sensitivity after Intravitreal Injection of Aflibercept in Eyes with Neovascular Age-Related Macular Degeneration with or without Polypoidal Choroidal Vasculopathy. Ophthalmologica. Journal international d'ophtalmologie. International journal of ophthalmology. Zeitschrift fur Augenheilkunde, 244(4), 347–360. https://doi.org/10.1159/000517187

  11. Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 30(1), 17–28. https://doi.org/10.1159/000509119






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