Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C.

BACKGROUND: Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations. OBJECTIVE: This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care. DESIGN: Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients. PARTICIPANTS: Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5). KEY RESULTS: All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care. CONCLUSIONS: Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.

Self-administered vaginal lidocaine gel for pain management with intrauterine device insertion: a blinded, randomized controlled trial.

BACKGROUND: A major barrier to intrauterine device use is fear of pain during insertion. Trials exploring analgesic interventions for intrauterine device insertion have yielded mixed results, and no standardized pain management guidelines currently exist for this procedure. In an abortion-related study, self-administered lidocaine gel over a prolonged time interval showed promise as a method of pain control. OBJECTIVE(S): The objective of the study was to assess pain control with intrauterine device insertion after patient-administered lidocaine gel compared with placebo. STUDY DESIGN: We conducted a randomized, blinded trial of women undergoing levonorgestrel or copper intrauterine device insertion in an outpatient gynecology clinic between July 2016 and April 2017. Participants self-administered either 20 mL of 2% lidocaine gel or placebo gel vaginally at least 15 minutes prior to intrauterine device insertion. No other analgesics were administered. The primary outcome was pain during intrauterine device insertion, measured on a 100-mm visual analog scale (0 being no pain and 100 being worst pain imaginable). Secondary outcomes included anticipated and baseline pain and pain with speculum insertion and tenaculum placement. In a postprocedure questionnaire, participants reported acceptability of vaginal gel and willingness to wait for pain control. Median values were assessed because of the nonnormal distribution of visual analog scale scores using the Mann-Whitney U test. Predictors of intrauterine device insertion pain were assessed using a multiple linear regression. RESULTS: In total, 220 women were randomized and 215 were included in analysis (108 in lidocaine gel, 107 in placebo gel groups). Median (range) time from gel administration to speculum insertion was 21 (14-74) and 20 (12-43) minutes in the lidocaine and placebo groups, respectively (P = .13). The median pain scores during intrauterine device insertion were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (P = .09). Among secondary outcome time points, only median pain scores at speculum insertion were significantly different between the lidocaine and placebo groups (7 [0-81] mm vs 11 [0-80] mm, respectively; P = .046). Anticipated pain and menstrual pain were both predictors of pain with intrauterine device insertion. The majority of women in both groups found the amount of vaginal leakage following gel insertion to be acceptable (>80%). Ninety-two percent of participants (n = 194) stated they would be willing to wait before intrauterine device placement for a potential analgesic effect. CONCLUSION: Self-administered lidocaine gel at least 15 minutes before intrauterine device insertion does not appear to reduce pain compared with placebo but may help with speculum insertion. We found that women are willing to extend visit time to gain pain control. Self-administration of local anesthetic is acceptable to patients and should be considered in future research.

Self-managed abortion.

PURPOSE OF REVIEW: To review the current state of self-managed or self-induced abortion in the United States and the emerging legal, political, and research questions surrounding this issue. RECENT FINDINGS: With the exponential rise of restrictive antiabortion laws in the United States, it has become increasingly difficult to access safe and legal abortion services. One response to this hostile environment for reproductive care access is an increased interest in methods of self-induced or self-managed abortions, primarily by medications sourced outside the medical setting. Medication abortion is established as a safe and effective method of ending a pregnancy. Compared with clinic-based care, the two most pressing concerns regarding the safety of self-managed abortion are that people seeking abortion will incorrectly self-identifying as appropriate candidates and that they will not know or be able to access medical care if needed. There is therefore an increasing need for medical providers to learn about and researchers to evaluate the incidence, safety and efficacy of self-management of abortion. Simultaneously, reproductive law experts must continue to develop and educate on the legal frameworks to protect and decriminalize people seeking self-managed abortion as well as their care providers. SUMMARY: Emerging research suggests that abortion outside the medical setting, or self-managed abortion, is an overall safe and effective way to end a pregnancy. However, significant legal barriers and stigma remain. The safest environment for self-managed abortion (SMA) is one where accurate information is available, medical care is accessible when needed, and all methods of abortion remain legal.

Abortion in the media.

PURPOSE OF REVIEW: To review updates in how abortion care is depicted and analysed though various media outlets: news, television, film, and social media. RECENT FINDINGS: A surge in recent media-related abortion research has recognized several notable and emerging themes: abortion in the news media is often inappropriately sourced and politically motivated; abortion portrayal in US film and television is frequently misrepresented; and social media has a new and significant role in abortion advocacy. SUMMARY: The portrayal of abortion onscreen, in the news, and online through social media has a significant impact on cultural, personal, and political beliefs in the United States. This is an emerging field of research with wide spread potential impact across several arenas: medicine, policy, public health.

Update on abortion policy.

PURPOSE OF REVIEW: To review the status of antiabortion restrictions enacted over the last 5 years in the United States and their impact on abortion services. RECENT FINDINGS: In recent years, there has been an alarming rise in the number of antiabortion laws enacted across the United States. In total, various states in the union enacted 334 abortion restrictions from 2011 to July 2016, accounting for 30% of all abortion restrictions since the legalization of abortion in 1973. Data confirm, however, that more liberal abortion laws do not increase the number of abortions, but instead greatly decrease the number of abortion-related deaths. Several countries including Romania, South Africa and Nepal have seen dramatic decreases in maternal mortality after liberalization of abortion laws, without an increase in the total number of abortions. In the United States, abortions are incredibly safe with very low rates of complications and a mortality rate of 0.7 per 100 000 women. With increasing abortion restrictions, maternal mortality in the United States can be expected to rise over the coming years, as has been observed in Texas recently. SUMMARY: Liberalization of abortion laws saves women's lives. The rising number of antiabortion restrictions will ultimately harm women and their families.

Update on long-acting reversible methods.

PURPOSE OF REVIEW: The last several years have seen a number of important clinical and academic advances in long-acting reversible contraceptive (LARC) methods, such that many professional medical organizations now recommend these methods as first-line contraception for all women. RECENT FINDINGS: Recent data support the use of LARC in a variety of special circumstances including adolescents, nulliparous women and immediately postpartum and postabortion. Evidence also shows that traditional methods of pain control with intrauterine device (IUD) insertion and cervical preparation prior to insertion may not be warranted. Further, the extended use of IUDs is safer and more effective than previously realized. SUMMARY: The rising uptake of LARC methods in the United States has the potential to dramatically decrease undesired pregnancies and abortion rates, and should be considered an effective option in the majority of women.

Will all youth answer sexual orientation and gender-related survey questions? An analysis of missingness in a large U.S. survey of adolescents and young adults.

Some researchers and clinicians may feel hesitant to assess sexual orientation and gender-related characteristics in youth surveys because they are unsure if youth will respond to these questions or are concerned the questions will cause discomfort or offense. This can result in missed opportunities to identify LGBTQ+ youth and address health inequities among this population. The aim of this study was to examine the prevalence and sociodemographic patterns of missingness among survey questions assessing current sexual orientation, gender identity and expression (SOGIE), and past change in sexual orientation (sexual fluidity) among a diverse sample of U.S. youth. Participants (N = 4,245, ages 14-25 years; 95% cisgender, 70% straight/heterosexual, 53% youth of color), recruited from an online survey panel, completed the Wave 1 survey of the longitudinal Sexual Orientation Fluidity in Youth (SO*FLY) Study in 2021. Current SOGIE, past sexual fluidity, and sociodemographic characteristics were assessed for missingness. Overall, 95.7% of participants had no missing questions, 3.8% were missing one question, and 0.5% were missing ≥ 2 questions. Past sexual fluidity and assigned sex were most commonly missing. Sociodemographic differences between participants who skipped the SOGIE questions and the rest of the sample were minimal. Missingness for the examined items was low and similar across sociodemographic characteristics, suggesting that almost all youth are willing to respond to survey questions about SOGIE. SOGIE and sexual fluidity items should be included in surveys and clinical assessments of youth to inform clinical care, policy-making, interventions, and resource development to improve the health of all youth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Needs for Successful Engagement in Telemedicine Among Rural Older US Veterans and Their Caregivers: Qualitative Study.

BACKGROUND: Telemedicine is an important option for rural older adults who often must travel far distances to clinics or forgo essential care. In 2014, the Geriatric Research, Education, and Clinical Centers (GRECC) of the US Veterans Health Administration (VA) established a national telemedicine network called GRECC Connect. This network increased access to geriatric specialty care for the 1.4 million rural VA-enrolled veterans aged 65 years or older. The use of telemedicine skyrocketed during the COVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access as overburdened systems shut down in-person services. This surge presented a unique opportunity to study the supports necessary for those who would forgo telemedicine if in-person care were available. OBJECTIVE: In spring 2021, we interviewed veterans and their informal caregivers to (1) elicit their experiences attempting to prepare for a video visit with a GRECC Connect geriatric specialist and (2) explore facilitators and barriers to successful engagement in a telemedicine visit. METHODS: We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate in at least 1 GRECC Connect telemedicine visit in the previous 3 months. A total of 30 participants from 6 geographically diverse GRECC Connect hub sites agreed to participate. Semistructured interviews were conducted through telephone or the VA's videoconference platform for home telemedicine visits (VA Video Connect) per participant preference. We observed challenges and, when needed, provided real-time technical support to facilitate VA Video Connect use for interviews. All interviews were recorded with permission and professionally transcribed. A team of 5 researchers experienced in qualitative research analyzed interview transcripts using rapid qualitative analysis. RESULTS: From 30 participant interviews, we identified the following 4 categories of supports participants described regarding successful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: (1) caregiver presence to facilitate technology setup and communication; (2) flexibility in visit modality (eg, video from home or a clinic or telephone); (3) technology support (eg, determining device compatibility or providing instruction and on-demand assistance); and (4) assurance of comfort with web-based communication, including orientation to features like closed captioning. Supports were needed at multiple points before the visit, and participants stressed the importance of eliciting the varying needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because of pandemic-related clinic closures, participants were satisfied with telemedicine and willing to use it for other types of health care visits. CONCLUSIONS: To close gaps in telemedicine use among rural older adults, supports must be tailored to individuals, accounting for technology availability and comfort, as well as availability of and need for caregiver involvement. Comprehensive scaffolding of support starts well before the first telemedicine visit.

The Development and Use of a New Visual Tool (REVISIT) to Support Participant Recall: Web-Based Interview Study Among Older Adults.

BACKGROUND: Qualitative health services research often relies on semistructured or in-depth interviews to develop a deeper understanding of patient experiences, motivations, and perspectives. The quality of data gathered is contingent upon a patient's recall capacity; yet, studies have shown that recall of medical information is low. Threats to generating rich and detailed interview data may be more prevalent when interviewing older adults. OBJECTIVE: We developed and studied the feasibility of using a tool, Remembering Healthcare Encounters Visually and Interactively (REVISIT), which has been created to aid the recall of a specific telemedicine encounter to provide health services research teams with a visual tool, to improve qualitative interviews with older adults. METHODS: The REVISIT visual appointment summary was developed to facilitate web-based interviews with our participants as part of an evaluation of a geriatric telemedicine program. Our primary aims were to aid participant recall, maintain focus on the index visit, and establish a shared understanding of the visit between participants and interviewers. The authors' experiences and observations developing REVISIT and using it during videoconference interviews (N=16) were systematically documented and synthesized. We discuss these experiences with REVISIT and suggest considerations for broader implementation and future research to expand upon this preliminary work. RESULTS: REVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants. REVISIT appeared to support older patients' and caregivers' recollection of a clinical visit, helping them to share additional details about their experience. REVISIT was difficult to read for some participants, however, and could not be used for phone interviews. CONCLUSIONS: REVISIT is a promising tool to enhance the quality of data collected during interviews with older, rural adults and caregivers about a health care encounter. This novel tool may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data (eg, those with cognitive impairment or complex medical care), allowing health services research to include more diverse patient experiences.

Real-world evaluation of a two-step testing algorithm for Clostridioides difficile infection.

During the 4 years after implementation of the 2-step Clostridioides difficile infection (CDI) testing algorithm, 70% to 78% of patients with suspected CDI and a positive nucleic acid amplification test but a negative toxin test (NAAT+/TOX-) received CDI treatment. Overall, 73% of NAAT+/TOX- patients were classified as having probable or possible CDI.

Patient and provider perspectives of personal health record use: a multisite qualitative study in HIV care settings.

Use of tethered personal health records (PHRs) can streamline care, reduce unnecessary care utilization, and improve health outcomes for people living with human immunodeficiency virus (HIV). Providers play a role in influencing patients' decision to adopt and use PHRs. To explore patient and provider acceptance and use of PHRs in an HIV care setting. We used a qualitative study design guided by the Unified Theory of Acceptance and Use of Technology. Participants included providers of HIV care, patients living with HIV, and PHR coordinating and support staff in the Veterans Health Administration (VA). Interviews were analyzed using directed content analysis. We interviewed providers (n = 41), patients living with HIV (n = 60), and PHR coordinating and support staff (n = 16) at six VA Medical Centers between June and December 2019. Providers perceived PHR use could enhance care continuity, appointment efficiency, and patient engagement. Yet, some expressed concerns that patient PHR use would increase provider workload and detract from clinical care. Concerns about poor PHR interoperability with existing clinical tools further eroded acceptance and use of PHRs. PHR use can enhance care for patients with HIV and other complex, chronic conditions. Negative provider attitudes toward PHRs may impact providers' encouragement of use among patients, consequently limiting patient uptake. Multipronged interventions at the individual, institutional, and system level are needed to enhance PHR engagement among both providers and patients.

Personal health records, also known as patient portals, allow patients to see personal health information on their computers or phones. Patients who use portals can address many health needs without going to their doctor's office. In our study, we wanted to understand why patients living with human immunodeficiency virus (HIV) may choose not to use patient portals. We talked to 60 patients with HIV, 41 medical providers, and 16 portal support staff from six United States Veterans Affairs (VA) hospitals. We learned that providers influence patient decisions to use patient portals­patients were more likely to consider using a patient portal when their providers talked to them about it. However, some providers felt they did not have the time to talk about portals. They also did not feel prepared to support patients who needed help using them. Providers were more likely to talk about patient portals if they saw their benefits and if they felt their patients use them. Some patients were concerned about the security of the information on their patient portals. To increase portal use among patients with HIV, hospitals should address the concerns that patients and providers have about portals while also highlighting the benefits of portal use.

Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers.

OBJECTIVE: Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value. DATA SOURCES: In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits. STUDY DESIGN: A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges. DATA COLLECTION: We conducted 30 semi-structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach. PRINCIPAL FINDINGS: Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity). CONCLUSIONS: Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.

Development and Validation of Quality Measures for Testosterone Prescribing.

Context: Accurate measures to assess appropriateness of testosterone prescribing are needed to improve prescribing practices. Objective: This work aimed to develop and validate quality measures around the initiation and monitoring of testosterone prescribing. Methods: This retrospective cohort study comprised a national cohort of male patients receiving care in the Veterans Health Administration who initiated testosterone during January or February 2020. Using laboratory data and diagnostic codes, we developed 9 initiation and 7 monitoring measures. These were based on the current Endocrine Society guidelines supplemented by expert opinion and prior work. We chose measures that could be operationalized using national VA electronic health record (EHR) data. We assessed criterion validity for these 16 measures by manual review of 142 charts. Main outcome measures included positive and negative predictive values (PPVs, NPVs), overall accuracy (OA), and Matthews Correlation Coefficients (MCCs). Results: We found high PPVs (>78%), NPVs (>98%), OA (≥94%), and MCCs (>0.85) for the 10 measures based on laboratory data (5 initiation and 5 monitoring). For the 6 measures relying on diagnostic codes, we similarly found high NPVs (100%) and OAs (≥98%). However, PPVs for measures of acute conditions occurring before testosterone initiation (ie, acute myocardial infarction or stroke) or new conditions occurring after initiation (ie, prostate or breast cancer) PPVs were much lower (0% to 50%) due to few or no cases. Conclusion: We developed several valid EHR-based quality measures for assessing testosterone-prescribing practices. Deployment of these measures in health care systems can facilitate identification of quality gaps in testosterone-prescribing and improve care of men with hypogonadism.

Dysmenorrhoea as a risk factor for pain with intrauterine device insertion.

BACKGROUND: Understanding predictors of pain with gynaecological procedures may facilitate individualised counselling and pain management. We aimed to study the effect of dysmenorrhoea on intrauterine device (IUD) insertion pain. METHODS: This was a planned secondary analysis of a randomised trial evaluating self-administered lidocaine gel versus placebo for IUD insertion pain. We included those participants who reported menses in the past 3 months. We assessed dysmenorrhoea (in the past 3 months) and procedural pain using a 100 mm visual analogue scale (VAS). We categorised dysmenorrhoea as none/mild (<40 mm), moderate (40-69 mm) or severe (≥70 mm). We assessed participant pain scores at speculum insertion, tenaculum placement, IUD insertion, and overall. We compared median procedural pain scores by dysmenorrhoea group with three-way and post hoc pairwise analyses. RESULTS: We analysed 188 participants. Demographic characteristics were similar among the three dysmenorrhoea groups. Pairwise comparisons revealed higher median procedural pain scores in the severe dysmenorrhoea group compared with the none/mild dysmenorrhoea group at speculum insertion (25 mm vs 8 mm; p=0.007), tenaculum placement (51 mm vs 31 mm; p=0.04) and IUD insertion (74 mm vs 61 mm; p=0.04). Overall pain did not differ among the three groups (p=0.32). CONCLUSIONS: Patients with severe dysmenorrhoea experienced increased pain with all aspects of IUD insertion, including speculum and tenaculum placement, compared with those with only mild or no dysmenorrhoea. Clinicians may consider this finding when providing individualised counselling and pain management for patients undergoing IUD insertion and other gynaecological procedures. Larger studies are needed to validate the effect of dysmenorrhoea severity on pain throughout IUD insertion.

Longitudinal high-frequency ethnographic interviewing to simulate and prepare for intensive smartphone data collection among veterans with homeless experience.

Objective: While Veteran homelessness has steadily declined over the last decade, those who continue to be unhoused have complex health and social concerns. Housing instability interferes with access to healthcare, social services, and treatment adherence. Preventing unwanted housing transitions is a public health priority. This study is the first phase of a larger research agenda that aims to test the acceptability and feasibility of smartphone-enabled data collection with veterans experiencing homelessness. In preparation for the development of the smartphone data collection application, we utilized ethnographic methods guided by user-centered design principles to inform survey content, approach to recruitment and enrollment, and design decisions. Methods: We used a case study design, selecting a small sample (n = 10) of veterans representing a range of homelessness experiences based on risk and length of time. Participants were interviewed up to 14 times over a 4-week period, using a combination of qualitative methods. Additionally, 2 focus group discussions were conducted. Interviews were audio-recorded and transcribed. Data were synthesized and triangulated through use of rapid analysis techniques. Results: All participants had experience using smartphones and all but one owned one at the time of enrollment. Participants described their smartphones as "lifelines" to social network members, healthcare, and social service providers. Social relationships, physical and mental health, substance use, income, and housing environment were identified as being directly and indirectly related to transitions in housing. Over the course of ~30 days of engagement with participants, the research team observed dynamic fluctuations in emotional states, relationships, and utilization of services. These fluctuations could set off a chain of events that were observed to both help participants transition into more stable housing or lead to setbacks and further increase vulnerability and instability. In addition to informing the content of survey questions that will be programmed into the smartphone app, participants also provided a broad range of recommendations for how to approach recruitment and enrollment in the future study and design features that are important to consider for veterans with a range of physical abilities, concerns with trust and privacy, and vulnerability to loss or damage of smartphones. Conclusion: The ethnographic approach guided by a user-centered design framework provided valuable data to inform our future smartphone data collection effort. Data were critical to understanding aspects of day-to-day life that important to content development, app design, and approach to data collection.

Self-administered lidocaine gel for local anesthesia prior to osmotic dilator placement: a randomized trial.

OBJECTIVE(S): To compare pain scores during cervical dilator placement prior to dilation and evacuation (D&E) with patient-administered vaginal lidocaine gel versus lidocaine paracervical block (PCB). STUDY DESIGN: We conducted an unblinded randomized trial of women ≥18 years of age undergoing surgical abortion at ≥16 weeks' gestation in two outpatient clinics. We randomized participants to receive self-administered lidocaine gel 2% 20 mL intravaginally 15-30 min before procedure initiation or lidocaine 1% 12 mL PCB immediately prior to dilator placement. Participants rated their pain at various time points using a visual analog scale (VAS), including anticipated and baseline pain, speculum insertion, tenaculum placement, cervical dilator placement (primary outcome) and speculum removal. RESULTS: We enrolled 72 women and analyzed data for 69 participants. Sociodemographic characteristics and VAS scores at all time points, except for anticipated pain, were similar between groups. The median pain score with dilator placement was 48 mm in the gel group and 61 mm in the PCB group (p=.23). Procedure times for the gel group and PCB group were 3.7 min and 5.2 min, respectively (p<.01). Lidocaine gel was noninferior to PCB for reported pain scores (VAS) with dilator placement, with a difference in means of -8 mm (95% CI -21, 5) favoring the gel. CONCLUSIONS: Self-administration of lidocaine gel prior to placement of cervical dilators for D&E is noninferior to paracervical lidocaine block for local anesthesia and is a potential alternative to PCB for pain management with osmotic dilator placement. IMPLICATIONS: Lidocaine gel and similar products represent noninvasive, nonpainful methods of local anesthesia for a variety of outpatient gynecologic procedures. Given our noninferiority findings, if gel anesthetics are available, they should be considered as an alternative to paracervical block.

Comparison of keyboard colonization before and after use in an inpatient setting and the effect of keyboard covers.

Computer keyboards may contribute to patient infections. We cultured new keyboards, with/without keyboard covers, before placing them in adult inpatient rooms and recultured after 6 months. Nonpathogenic bacteria were present initially but potentially pathogenic bacteria were cultured only after use. Coagulase negative Staphylococcus colonization increased after use (P < .001). Keyboards with a cover had more potentially pathogenic bacteria (22% vs 16%), which although not significant statistically (P = .72), likely due to sample size, trended against covers offering protection.

Self-Administered Lidocaine Gel for Pain Control With First-Trimester Surgical Abortion: A Randomized Controlled Trial.

OBJECTIVE: To compare pain control at various time points during first-trimester surgical abortion using a patient-administered lidocaine gel compared with a traditional lidocaine paracervical block. METHODS: We conducted a randomized controlled trial of women undergoing surgical abortion at less than 12 weeks of gestation in an outpatient setting. The primary outcome was pain at cervical dilation as measured on a 100-mm visual analog scale. A sample size of 142 participants was planned to detect a 15-mm or greater difference on the 100-mm visual analog scale with 90% power and a significance level of .025, adding 10% for participant dropout and protocol violations. Participants received either 12 mL of a 1% lidocaine paracervical block or 20 mL of a self-administered, 2% lidocaine gel 20-30 minutes before procedure initiation. Secondary outcomes included anticipated pain, baseline pain, pain with speculum and tenaculum placement, pain after suction aspiration, and pain 30-45 minutes postoperatively. RESULTS: From April to October 2015, a total of 142 women were enrolled (68 in the paracervical block group, 69 in the gel group, and five not analyzed as a result of participant withdrawal). Sociodemographic characteristics were similar between groups. The mean pain score with cervical dilation was 60 mm (95% confidence interval [CI] 54-66) in the paracervical block group and 64 mm (95% CI 59-69) in the gel group (P=.3). There was no significant difference between mean pain scores at any time points measured. CONCLUSION: Self-administration of lidocaine gel before first-trimester surgical abortion is noninferior to a traditional paracervical lidocaine block and should be considered as an alternative, noninvasive approach to pain control for first-trimester surgical abortion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02447029.