In Support of Breast/Chest Feeding by People with HIV in High-Income Settings.

Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the United States and other resource rich settings was actively discouraged. Formula feeding was mandated as the only feeding option primarily out of concern for breastmilk transmission of HIV, which occurred in 16-24%1-3 of cases pre-antiretroviral therapy (ART) use. In January 2023, the United States' Department of Health and Human Services (DHHS) Perinatal Guidelines were updated to support shared decision making for infant feeding choices4. Updated data from clinical trials in low- and middle-income settings suggest that the actual rate of HIV transmission through breastmilk in the context of maternal ART or neonatal post-exposure prophylaxis (PEP) is 0.3-1%1-3. High income countries are reporting increasing numbers of people with HIV breastfeeding their infants without cases of HIV transmission to date5-10. Here we will present the reasons for fully embracing breast/chestfeeding as a viable and safe infant feeding option for HIV-exposed infants in high-income settings now, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.

Syphilis Diagnosis After a Chlamydia, Gonorrhea, or HIV Diagnosis Among Reproductive-Aged Women in Baltimore, MD.

BACKGROUND: Syphilis incidence is increasing among reproductive-aged women, and previous sexually transmitted infections (STIs) are a risk factor for subsequent STIs. This study aimed to determine syphilis incidence after a chlamydia, gonorrhea, or HIV diagnosis, and identify characteristics associated with higher syphilis incidence rates among reproductive-aged women in 1 mid-Atlantic city. METHODS: A retrospective cohort of 85,113 chlamydia, gonorrhea, and HIV diagnoses occurring between 2009 and 2021 and among women aged 13 to 50 years was constructed using public health surveillance data. Cumulative incidence curves were estimated to examine time to early syphilis (i.e., primary, secondary, or early latent) diagnosis, and multivariable analyses determined incidence rate ratios by age (<25 vs. ≥25 years) and number of prior STI diagnoses (0 vs. ≥1) during the study period, stratified by STI. RESULTS: There were 85,113 reportable STI diagnoses and 646 syphilis diagnoses in the cohort. Approximately 1 of 150 chlamydia, 1 of 100 gonorrhea, and 1 of 50 HIV diagnoses were followed by a syphilis diagnosis within 5 years. Cumulative incidence of syphilis differed significantly by STI diagnosis ( P < 0.001). In multivariable analysis, syphilis incidence rates were higher among women diagnosed with ≥1 (vs. 0) prior STI regardless of STI type ( P < 0.05) and among women ≥25 (vs. <25) years old diagnosed with gonorrhea ( P < 0.05). CONCLUSIONS: There were significant differences in syphilis incidence by prior STI type, number of STIs, and age. Our data support targeted screening for syphilis among women with a history of STIs, parwomen with ≥1 prior STI diagnosis, and older women diagnosed with gonorrhea.

Severely Restricting Abortion Threatens Equitable Health Outcomes for People With Human Immunodeficiency Virus.

Equitable access to abortion is a critical component of reproductive care. Women with human immunodeficiency virus (HIV) in the United States are disproportionately Black and will be disproportionately affected by abortion bans following the Supreme Court's decision to overturn Roe v Wade. We argue that this decision is directly in conflict with the National HIV/AIDS Strategies and Centers for Disease Control and Prevention's goals to eliminate perinatal HIV transmission.

Breastfeeding Among People With Human Immunodeficiency Virus in North America: A Multisite Study.

BACKGROUND: In North American countries, national guidelines have strongly recommended formula over breastmilk for people with human immunodeficiency virus (HIV) because of concern for HIV transmission. However, data from resource-limited settings suggest the risk is <1% among virally suppressed people. Information regarding breastfeeding experience in high-resource settings is lacking. METHODS: A retrospective multisite study was performed for individuals with HIV who breastfed during 2014-2022 in the United States (8 sites) and Canada (3 sites). Descriptive statistics were used for data analysis. RESULTS: Among the 72 cases reported, most had been diagnosed with HIV and were on antiretroviral therapy prior to the index pregnancy and had undetectable viral loads at delivery. Most commonly reported reasons for choosing to breastfeed were health benefits, community expectations, and parent-child bonding. Median duration of breastfeeding was 24 weeks (range, 1 day to 72 weeks). Regimens for infant prophylaxis and protocols for testing of infants and birthing parents varied widely among institutions. No neonatal transmissions occurred among the 94% of infants for whom results were available ≥6 weeks after weaning. CONCLUSIONS: This study describes the largest cohort to date of people with HIV who breastfed in North America. Findings demonstrate high variability among institutions in policies, infant prophylaxis, and infant and parental testing practices. The study describes challenges in weighing the potential risks of transmission with personal and community factors. Finally, this study highlights the relatively small numbers of patients with HIV who chose to breastfeed at any 1 location, and the need for further multisite studies to identify best care practices.

The impact of anxiety on postoperative pain following pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: Despite the prevalence of anxiety, its impact on postoperative pain remains poorly characterized. The present study was aimed at assessing the impact of preoperative anxiety on postoperative pain in patients undergoing pelvic reconstructive surgery. We hypothesized that greater anxiety would be associated with increased postoperative pain for patients undergoing pelvic reconstructive surgery. METHODS: This was a prospective multi-center observational study in Baltimore between September 2018 and June 2019. The Beck Anxiety Inventory was used to assess preoperative anxiety and the validated Surgical Pain Scale instrument was used to assess pain in the postoperative period. The association between anxiety and postoperative pain was analyzed using multivariate logistic regression, adjusting for relevant confounders. RESULTS: A total of 149 patients undergoing pelvic reconstructive surgery completed preoperative surveys. The median age of the study population was 59. The prevalence of preoperative anxiety (anxiety score > 9) in our study population was 26.8% (95% CI 19.7-34.0%). Women with preoperative anxiety reported higher postoperative pain on days 1-2 (relative odds 1.05, 95% confidence interval 1.01-1.10) and day 14 (relative odds 1.53, 95% confidence interval 1.00-2.34). CONCLUSIONS: A large fraction of women undergoing pelvic reconstructive surgery have moderate to severe preoperative anxiety. Women with preoperative anxiety appear to have greater odds of increased postoperative pain. Understanding this association may help surgeons with preoperative counseling and expectations regarding postoperative pain.

Satisfaction with opioid prescription and use after minor gynaecologic surgery: a pilot prospective study.

To describe predictors of patient satisfaction with pain control including opioid prescribing practices, patients undergoing minor gynaecologic and urogynaecologic surgeries were included in a prospective cohort study. Satisfaction with postoperative pain control by opioid prescription status was analysed using bivariate analysis and multivariable logistic regression, controlling for potential confounders. Among participants completing both postoperative surveys, 112/141 (79.4%) reported pain control satisfaction by day 1-2 and 118/137 (86.1%) by day 14. While we were underpowered to detect a true difference in satisfaction by opioid prescription, there were no differences in opioid prescription among patients satisfied with pain control [52% vs. 60% (p = .43) among satisfied patients at day 1-2 and 58.5% vs. 37% (p = .08) at day 14]. Significant predictors of pain control satisfaction were postoperative day (POD) 1-2 average pain at rest [aOR 0.72 (95% CI 0.52-0.99), p = .04], rating of shared decision-making [aOR 1.16 (95% CI 1.004-1.34), p = .04], amount of pain relief [aOR 1.28 (95% CI 1.07-1.54), p = .008) and POD 14 shared decision-making rating [aOR 1.45 (95% CI 1.19-1.77), p = .002].Impact StatementWhat is already known on this subject? There are little data published on opioid prescription rates after minor gynaecologic procedures and no formal evidence-based guidance for gynaecologic providers for opioid prescribing. Few publications describe rates of opioid prescription and use following minor gynaecologic procedures. In the setting of a dramatic escalation of opioid misuse in the United States over the last decade, we sought to describe our practice of opioid prescription following minor gynaecologic procedures and answer the question of whether patient satisfaction is affected by opioid prescription, fill and use.What do the results of this study add? Though underpowered to detect our primary outcome, our results suggest that patient satisfaction with pain control may primarily be significantly affected by the patient's subjective assessment of shared decision-making with the gynaecologist.What are the implications of these findings for clinical practice and/or further research? Ultimately, these preliminary findings suggest a larger cohort is needed to answer the question of whether pain control satisfaction is influenced by receipt/fill/use of opioids after minor gynaecologic surgery.

Hospital Development of a Hybrid Emergency Department-Inpatient Care Observation Unit.

INTRODUCTION: This project aimed to design and implement an emergency department-managed observation unit that improves inpatient bed and emergency department stretcher capacity, decreases observation patient length of stay, earns high patient satisfaction scores, and generates a positive fiscal impact on the organization. METHODS: This quality improvement project followed a 1-group, pre- and postprogram implementation design. RESULTS: In the first year of operations, 40% of the total observation patients treated in this hospital were managed in the new observation unit. Emergency department observation unit length of stay across all patient complaints was half of the average length of stay for observation patients located on hospital inpatient units. In most cases, the emergency department observation unit was in the top 25 percentile of hospital Press Ganey inpatient satisfaction categories. The hospital estimates a contribution margin of three-quarters of a million dollars in the first year. DISCUSSION: This effective and efficient hybrid observation unit possessed specific aspects of inpatient and emergency department patient care models. Placing providers and nurses at the workstation for faster communication expedited care. Prioritizing all observation patient testing, transportation, phlebotomy, and intravenous (IV) services shortened disposition times. Emergency nurses transitioning to the observation unit were challenged to acquire inpatient care knowledge. Observation unit management struggled to maintain staffing while under an inpatient productivity model managed by the inpatient house supervisor. Reducing patient disposition time required clear communication between observation unit and inpatient staffing managers, between physician consultants and advanced practice nursing providers, and among nurses, patients, and providers. Observation units are 1 solution to decrease observation patient length of stay and improve emergency department capacity.

Modelling the effect of COVID-19 mass vaccination on acute hospital admissions.

BACKGROUND: Managing high levels of acute COVID-19 bed occupancy can affect the quality of care provided to both affected patients and those requiring other hospital services. Mass vaccination has offered a route to reduce societal restrictions while protecting hospitals from being overwhelmed. Yet, early in the mass vaccination effort, the possible impact on future bed pressures remained subject to considerable uncertainty. OBJECTIVE: The aim of this study was to model the effect of vaccination on projections of acute and intensive care bed demand within a 1 million resident healthcare system located in South West England. METHODS: An age-structured epidemiological model of the susceptible-exposed-infectious-recovered type was fitted to local data up to the time of the study, in early March 2021. Model parameters and vaccination scenarios were calibrated through a system-wide multidisciplinary working group, comprising public health intelligence specialists, healthcare planners, epidemiologists and academics. Scenarios assumed incremental relaxations to societal restrictions according to the envisaged UK Government timeline, with all restrictions to be removed by 21 June 2021. RESULTS: Achieving 95% vaccine uptake in adults by 31 July 2021 would not avert the third wave in autumn 2021 but would produce a median peak bed requirement ∼6% (IQR: 1-24%) of that experienced during the second wave (January 2021). A 2-month delay in vaccine rollout would lead to significantly higher peak bed occupancy, at 66% (11-146%) of that of the second wave. If only 75% uptake was achieved (the amount typically associated with vaccination campaigns), then the second wave peak for acute and intensive care beds would be exceeded by 4% and 19%, respectively, an amount which would seriously pressure hospital capacity. CONCLUSION: Modelling influenced decision-making among senior managers in setting COVID-19 bed capacity levels, as well as highlighting the importance of public health in promoting high vaccine uptake among the population. Forecast accuracy has since been supported by actual data collected following the analysis, with observed peak bed occupancy falling comfortably within the inter-quartile range of modelled projections.

Characterization of the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) in Lung Transplant Candidates.

The SIPAT is a standardized measure for pre-transplant psychosocial evaluation. Previous SIPAT studies utilized a relatively small lung transplant sample and only included listed patients. This study characterized the SIPAT in 147 lung transplant candidates to better elucidate its utility. The average score corresponded to a minimally acceptable rating and nearly half of the patients had relative or absolute contraindications. Interstitial Lung Disease (ILD) patients scored more favorably than non-ILD patients (U = 7.69, p < .05). The Total (ß = - .05, SE = .018, p < .01), Social Support Subscale (ß = - .133, SE = .058, p < .05), and Psychosocial Stability and Psychopathology Subscale (ß = - .103, SE = .040, p < .05) significantly predicted listing status. The SIPAT has a unique profile in lung transplant candidates and demonstrated utility for guiding transplant decisions. Future research should examine which lung transplant outcomes are significantly associated with SIPAT scores.

Data on Safety of Intravaginal Boric Acid Use in Pregnant and Nonpregnant Women: A Narrative Review.

ABSTRACT: Intravaginal boric acid (IBA) represents one of the only options available to treat azole-resistant vulvovaginal candidiasis (VVC) and is included as part of multiple national guidelines (including the United Kingdom and the United States) for the treatment of VVC or recurrent bacterial vaginosis. Novel products using IBA are under development for treatment and suppression of VVC and bacterial vaginosis. Use of over-the-counter or clinician-prescribed IBA in reproductive-aged women is already widespread and may increase further if drug resistance in VVC rises. However, IBA is not a Food and Drug Administration-approved drug, and safety data are sparse. Given these factors, it is important to understand the currently available data on the safety of IBA use. Herein, we set out to synthesize human and animal data (converting, where appropriate, dose and serum values to standard units to facilitate comparison) to answer 2 key questions: (1) What are the data on the safety of IBA use for women? and (2) What are the data on the safety of IBA use in pregnancy? We find that, despite gaps, available data suggest IBA use is safe, at least when used in doses commonly described in the literature as being prescribed by clinicians. Information on harms in pregnancy is limited, and data remain insufficient to change current guidelines, which recommend IBA avoidance in pregnancy.

Stable Encoding of Visual Cues in the Mouse Retrosplenial Cortex.

The rodent retrosplenial cortex (RSC) functions as an integrative hub for sensory and motor signals, serving roles in both navigation and memory. While RSC is reciprocally connected with the sensory cortex, the form in which sensory information is represented in the RSC and how it interacts with motor feedback is unclear and likely to be critical to computations involved in navigation such as path integration. Here, we used 2-photon cellular imaging of neural activity of putative excitatory (CaMKII expressing) and inhibitory (parvalbumin expressing) neurons to measure visual and locomotion evoked activity in RSC and compare it to primary visual cortex (V1). We observed stimulus position and orientation tuning, and a retinotopic organization. Locomotion modulation of activity of single neurons, both in darkness and light, was more pronounced in RSC than V1, and while locomotion modulation was strongest in RSC parvalbumin-positive neurons, visual-locomotion integration was found to be more supralinear in CaMKII neurons. Longitudinal measurements showed that response properties were stably maintained over many weeks. These data provide evidence for stable representations of visual cues in RSC that are spatially selective. These may provide sensory data to contribute to the formation of memories of spatial information.

A pilot study assessing the brain gauge as an indicator of cognitive recovery in alcohol dependence.

Alcohol dependence (AD) is associated with multiple cognitive deficits, which can affect treatment outcomes. Current measures of tracking brain recovery (e.g., functional magnetic resonance imaging) can be less accessible for practitioners. This study pilots a novel device (the brain gauge; BG) to assess its utility, and track recovery of cognitive function in residential alcohol treatment. METHODS: A repeated measures design assessed changes in cognitive function during detoxification. Twenty-one participants with AD (16 Male; Mean age 43.85 ± 6.21) completed a battery of alcohol and memory questionnaires and BG tasks at two time-points (∼days 4 and 10) during a single managed detoxification episode. RESULTS: Repeated measures ANCOVA revealed that some BG metrics significantly improved, with medium to large effect sizes - processing speed, focus, temporal order judgement and overall cortical metric. However, differences in subjective cognitive function were non-significant after controlling for depression and anxiety change scores. Anxiety change emerged as a significant factor in subjective cognitive function. CONCLUSIONS: We conclude it is possible that the prefrontal cortex (PFC) recovers more slowly compared to other brain areas, and there are compounding effects of improvements in anxiety and depression, and metacognitive deficits on subjective EF assessments. Future research should seek to validate the clinical utility of the BG by comparing against established neuroimaging methods.

Projecting the effect of easing societal restrictions on non-COVID-19 emergency demand in the UK: Statistical inference using public mobility data.

While it is well established that societal restrictions have been effective in reducing COVID-19 emergency demand, evidence also suggests an impact upon emergency demand not directly related to COVID-19 infection. Hospital planning may benefit from a greater understanding of this association and the ability to reliably forecast future levels of non-COVID-19 demand. Activity data for Accident and Emergency (A&E) attendances and emergency admissions were sourced for all hospitals within the Bristol, North Somerset and South Gloucestershire healthcare system. These were regressed upon publicly available mobility data obtained from Google's Community Mobility Reports for the local area. Seasonal trends were controlled for using time series decomposition. The models were used to predict non-COVID-19 emergency demand under the UK Government's plan to sequentially lift all restrictions by 21 June 2021, in addition to three alternative hypothetical relaxation strategies. Rates of public mobility within the local area were shown to account for 77% and 65% of the variance in non-COVID-19 related A&E attendances and emergency admissions respectively. Modelling supports an increase in emergency demand in line with the level and timing of societal restrictions, with significant increases to be expected upon the ending of all legal limits. This study finds that non-COVID-19 emergency demand associates with the level of societal restrictions, with rates of public mobility representing a key determinant. Through predictive modelling, healthcare systems can improve their demand forecasting in effectively managing hospital capacity.

Implementing Coordinated Specialty Care for First Episode Psychosis: A Review of Barriers and Solutions.

Specialized early interventions (SEI) for individuals diagnosed with a first episode of psychosis (FEP) are effective treatment modalities (Azrin et al. in Psychiatr Ann 45(11):548, https://doi.org/10.3928/00485713-20151103-05 , 2015). SEI offered immediately or shortly following a first episode improves functional and clinical outcomes for those individuals with, and at risk for, serious mental illness (SMI; Correll et al. in JAMA Psychiatry 75(6):555-565, https://doi.org/10.1001/jamapsychiatry.2018.0623 , 2018). In the United States, SEI programs referred to as Coordinated Specialty Care (CSC), have been utilized to provide a beneficial, team-based, multi-component method of treating FEP. However, despite the success, CSC programming is still met with considerable challenges. This article reviews existing CSC literature to identify and explore relevant barriers to successful implementation of CSC. Identified barriers include stigma, cultural competence, disengagement, measurement and evaluation, workforce development, implementation in rural areas, and financial stability. The ongoing efforts to address these barriers are described and areas for continued improvements are discussed.

Exploring the Developmental Impact of Cystic Fibrosis on Lung Transplant Candidacy: Considerations for Adulthood.

The average life expectancy for cystic fibrosis (CF) has increased over the past four decades resulting in a higher rate of adult CF patients. Adults seeking lung transplant to address CF-related advanced lung disease (ALD) represent a small, yet growing, subset of lung transplant recipients. Psychosocial factors such as adherence to medical recommendations, self-management of medical care, and caregiver support have been identified as positive prognostic factors in lung transplant outcomes. These factors are also implicated in the pediatric chronic illness literature and are crucial as patients begin to transition to a more autonomous and independent role in their own health management. Adults with CF facing ALD must navigate through another transitional phase as lung transplant requires additional supports and new expectations. A case series is used to highlight specific psychosocial considerations in this population and to explore the seemingly dichotomous relationship between independent self-management and caregiver support.

Special ambulatory gynecologic considerations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice.

The coronavirus disease 2019 pandemic has altered medical practice in unprecedented ways. Although much of the emphasis in obstetrics and gynecology to date has been on the as yet uncertain effects of coronavirus disease 2019 in pregnancy and on changes to surgical management, the pandemic has broad implications for ambulatory gynecologic care. In this article, we review important ambulatory gynecologic topics such as safety and mental health, reproductive life planning, sexually transmitted infections, and routine screening for breast and cervical cancer. For each topic, we review how care may be modified during the pandemic, provide recommendations when possible on how to ensure continued access to comprehensive healthcare at this time, and discuss ways that future practice may change. Social distancing requirements may place patients at higher risk for intimate partner violence and mental health concerns, threaten continued access to contraception and abortion services, affect prepregnancy planning, interrupt routine screening for breast and cervical cancer, increase risk of sexually transmitted infection acquisition and decrease access to treatment, and exacerbate already underlying racial and minority disparities in care and health outcomes. We advocate for increased use of telemedicine services with increased screening for intimate partner violence and depression using validated questionnaires. Appointments for long-acting contraceptive insertions can be prioritized. Easier access to patient-controlled injectable contraception and pharmacist-provided hormonal contraception can be facilitated. Reproductive healthcare access can be ensured through reducing needs for ultrasonography and laboratory testing for certain eligible patients desiring abortion and conducting phone follow-up for medication abortions. Priority for in-person appointments should be given to patients with sexually transmitted infection symptoms, particularly if at risk for complications, while also offering expedited partner therapy. Although routine mammography screening and cervical cancer screening may be safely delayed, we discuss society guideline recommendations for higher-risk populations. There may be an increasing role for patient-collected human papillomavirus self-samples using new cervical cancer screening guidelines that can be expanded considering the pandemic situation. Although the pandemic has strained our healthcare system, it also affords ambulatory clinicians with opportunities to expand care to vulnerable populations in ways that were previously underutilized to improve health equity.

No effect of a musical intervention on stress response to venepuncture in a neonatal population.

AIM: To investigate the effect of a musical intervention on neonatal stress response to venepuncture as measured by salivary cortisol levels and pain profile scores. METHODS: In a randomised control crossover trial, participants were randomised to both a control arm (sucrose) and intervention arm (sucrose and music) for routine venepuncture procedures. Salivary swabs were collected at baseline, 20 minutes post-venepuncture and 4 hours post-venepuncture. Pain levels were assessed using the Premature Infant Pain Profile (PIPP). A total of 16 preterm neonates participated in both arms to complete the study. RESULTS: Cortisol values were elevated at all timepoints in the intervention arm (baseline, 20 minutes, and 4 hours post-procedure) but not significantly so (P = .056, P = .3, and P = .575, respectively). Median change in cortisol values from baseline was +128.48 pg/mL (-47.66 to 517.02) at 20 minutes and +393.52 pg/mL (47.88-1221.34) at 4 hours post-procedure in the control arm compared to -69.564 pg/mL (-860.96 to 397.289) and +100.48 pg/mL (-560.46 to 842.99) at 20 minutes and 4 hours post-procedure in the intervention arm. There was no statistically significant difference observed between groups (P = .311 at 20 minutes, and P = .203 at 4 hours post-procedure). PIPP scores were not significantly different between study arms. CONCLUSION: Our findings did not support the additional benefit of music intervention on neonatal stress response to venepuncture in preterm infants.

Unexpected High Rates of Persistent Trichomonas vaginalis Infection in a Retrospective Cohort of Treated Pregnant Women.

BACKGROUND: Our primary objective was to determine the rate of persistent Trichomonas infection among pregnant women posttreatment. The secondary objective was to determine if oral multidose metronidazole was associated with fewer cases of persistent Trichomonas compared with single-dose treatment. METHODS: This is a retrospective cohort study of women diagnosed with genital Trichomonas vaginalis from 2008 to 2017. We calculated the rate of persistent Trichomonas by dividing the number of positive Trichomonas tests collected 21 days or longer posttreatment by the total number of women treated and retested. Bivariate analysis was performed to compare the rates of positive tests after single and multidose metronidazole. Multivariate logistic regression was used to evaluate factors associated with persistent infection. RESULTS: Five hundred forty-two women with 565 pregnancies were diagnosed with Trichomonas infection. The majority of subjects were prescribed either single-dose (n = 352) or multidose metronidazole (n = 74). Posttreatment Trichomonas tests were collected 21 days or longer in 326 subjects and 44% (143) were positive. Rates of positive Trichomonas tests among women receiving single-dose and multidose regimens were similar (45% vs. 40%, P = 0.50). Women who had ≥1 pregnancy affected by Trichomonas infection were more likely to have a positive test posttreatment (adjusted odds ratio, 20.1; 95% confidence interval, 1.9-215.3). Obese women were less likely to have a positive test posttreatment (adjusted odds ratio, 0.3; 95% confidence interval, 0.1-0.9). CONCLUSIONS: Given high rates of positive Trichomonas tests and increased detection with nucleic acid amplification tests (NAATs), all pregnant women should be retested with NAATs approximately 3 weeks posttreatment. Further studies are needed to determine the most effective treatment of Trichomonas infection in pregnant women.

Clinicians' Use of Intravaginal Boric Acid Maintenance Therapy for Recurrent Vulvovaginal Candidiasis and Bacterial Vaginosis.

A retrospective chart review characterized clinicians' use of maintenance intravaginal boric acid for women with recurrent vulvovaginal candidiasis or bacterial vaginosis. Average length of use was 13 months with high patient satisfaction and few adverse events. Prospective studies are needed to evaluate the efficacy of maintenance boric acid for these conditions.

Weaning From Long-term Opioid Therapy.

Opioid use for chronic noncancer pain poses a challenge to the gynecologist, and weaning opioids is often a goal for clinicians and patients. In some cases, opioid cessation can be achieved by weaning a patient's prescribed opioid or with symptomatic management with long-acting opioids or alpha2-adrenergic medications. This review imparts a basic understanding of the physiology of opioid withdrawal, strategies for achieving opioid abstinence, medications for treating the symptoms of withdrawal, and alternatives to opioid taper.