PrEP-aring the General Gynecologist to Offer HIV Pre-exposure Prophylaxis.

It is estimated that 450,000 American women are at increased risk of infection with human immunodeficiency virus (HIV), and yet only 7% have a prescription for pre-exposure prophylaxis (PrEP). PrEP is a safe and effective method of HIV infection prevention via a daily use of an oral combination antiretroviral pill or longer-acting intramuscular injections. Gynecologists are experts in women's sexual health, and provide over half of annual preventative health visits, but are not yet routinely providing PrEP to patients, citing lack of knowledge as a major barrier. The authors aim to provide the general gynecologist with the skills to expertly provide PrEP to their patients to reduce HIV infection.

Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Effective postoperative pain management is a crucial component of recovery following surgery. Narcotics are a cornerstone of postoperative analgesia, but can require a redosing requirement, encompass a lengthy list of side effects and adverse reaction risks, as well as carry a dependency potential. The national focus on decreasing opioid use has directly impacted postoperative pain management. Previous studies have reported the beneficial use of a single intraoperative injection of extended-release liposomal bupivacaine in postoperative pain management, however the same results have not been extensively studied in the urogynecology literature. OBJECTIVE: We sought to evaluate cumulative postoperative vaginal pain on days 1 and 3 after posterior vaginal wall surgery comparing study medication (extended-release liposomal bupivacaine) to placebo (saline). Secondary aims were to evaluate vaginal pain on postoperative day 7 and total morphine-equivalent narcotic usage on days 1, 3, and 7. STUDY DESIGN: This is a randomized, double-blinded, placebo-controlled trial with 100 subjects recruited from Walter Reed National Military Medical Center urogynecology clinic. All subjects were age >18 years and scheduled for surgery involving the posterior vaginal wall or muscularis (including posterior colporrhaphy, colpocleisis, sphincteroplasty, perineorrhaphy), excluding those with regular narcotic usage or concurrent pain management requiring the use of epidural anesthesia. A sample size of 96 patients was calculated. Subjects were randomized to receive either 20 mL of extended-release liposomal bupivacaine (Exparel) (Pacira Pharmaceuticals Inc, Parsippany, NJ) or 20 mL of placebo (saline) at the end of surgery. Concealed syringes were used and injected immediately postoperative into the lateral vaginal wall/levator muscle area and perineal body. In-house morphine-equivalent narcotic usage was recorded along with the postoperative day 1 pain scores. Patients were contacted by telephone on postoperative days 3 and 7. Vaginal pain scores were evaluated using the Defense and Veterans Pain Rating Scale, cumulatively and on days 1, 3, and 7. Overall morphine-equivalent narcotics were compared between the 2 groups. RESULTS: From October 2014 through August 2017, 100 patients were enrolled and completed the study; 49 (49%) of the patients were randomized to the study group and 51 (51%) were in the placebo group. There was no significant difference between vaginal pain scores between the study group and the placebo group (postoperative day 1: study medication median score 1 [interquartile range 0-3], placebo median score 1 [interquartile range 0-3] [P = .59]; postoperative day 3: study medication median score 2 [interquartile range 0-3], placebo median score 1 [interquartile range 0-3] [P = .20]; postoperative day 7: study medication median score 3 [interquartile range 1-4], placebo median score 1.5 [interquartile range 0-3] [P = .06]). Cumulative pain scores postoperative day 1-7 were also not significant (study medication median score 6 [interquartile range 1-10], placebo median score 4 [interquartile range 1-8] [P = .14]). Multivariate model for the presence of vaginal pain was calculated and after controlling for body mass index, age, and combined laparoscopy surgery, there was no significant difference between the study and the placebo groups (P = .62). There was no statistically significant difference in morphine equivalents for the 2 groups: study medication 112.5 (interquartile range 45-207) and placebo 101.5 (interquartile range 37.5-195), P = .81. CONCLUSION: The use of extended-release liposomal bupivacaine in posterior vaginal wall surgeries, injected into the lateral posterior vaginal wall and perineal body, does not provide a significant decrease in postoperative pain or decrease narcotic medication usage when compared to saline.

Detection of Wellfleet Bay Virus Antibodies in Sea Birds of the Northeastern USA.

Wellfleet Bay virus (WFBV) is a recently described orthomyxovirus isolated from the tissues of Common Eiders (Somateria mollissima) collected during recurrent mortality events on Cape Cod, Massachusetts, US. Coastal Massachusetts is the only location where disease or mortality associated with this virus has been detected in wild birds, and a previous seroprevalence study found a significantly higher frequency of viral exposure in eiders from this location than from other areas sampled in North America. This suggests that coastal Massachusetts is an epicenter of WFBV exposure, but the reason for this is unknown. Opportunistic sampling of sympatric species and testing of banked serum was used to investigate potential host range and spatiotemporal patterns of WFBV exposure. Antibodies were detected in Herring Gulls (Larus argentatus), Ring-billed Gulls (Larus delawarensis), a White-winged Scoter (Melanitta fusca), and a Black Scoter (Melanitta nigra). These findings demonstrate the likely occurrence of fall/winter transmission, expand our understanding of the host range of the virus, and provide further insight into the epidemiology of WFBV in the northeastern US.

PREVALENCE AND DISTRIBUTION OF WELLFLEET BAY VIRUS EXPOSURE IN THE COMMON EIDER (SOMATERIA MOLLISSIMA).

Between 1998 and 2014, recurrent mortality events were reported in the Dresser's subspecies of the Common Eider ( Somateria mollissima dresseri) on Cape Cod, Massachusetts, US near Wellfleet Harbor. The early die-offs were attributed to parasitism and emaciation, but beginning in 2006 a suite of distinct lesions was observed concomitant with the isolation of a previously unknown RNA virus. This novel pathogen was identified as an orthomyxovirus in the genus Quaranjavirus and was named Wellfleet Bay virus (WFBV). To assess evidence of exposure to this virus in Common Eiders, we conducted a longitudinal study of the prevalence of WFBV antibodies at multiple locations from 2004-14; we collected 2,258 serum samples from six locations and analyzed each using a microneutralization assay. Results corroborate the emergence of WFBV in 2006 based on the first detection of antibodies in that year. Significantly higher prevalence was detected in Common Eiders sampled in Massachusetts compared to those in Maine, Nova Scotia, and Québec. For birds breeding and wintering in Massachusetss, viral exposure varied by age, sex, and season of sampling, and prevalence by season and sex were highly interrelated with greater numbers of antibody-positive males in the autumn and females in the spring. No evidence of viral exposure was detected in the Northern subspecies ( Somateria mollissima borealis). Among the locations sampled, Massachusetts appears to be the epicenter of Common Eider exposure to WFBV. Further research is warranted to understand the factors controlling the epidemiology of WFBV in Massachussetts, including those that may be limiting geographic expansion of this virus.

Sacral Neuromodulation for the Treatment of Persistent Genital Arousal Disorder.

BACKGROUND: Patients affected with persistent genital arousal disorder report unprovoked, excessive, and unremitting genital arousal unrelated to sexual desire. Those afflicted experience severe physical and psychological distress with significant feelings of shame, guilt, and frustration. Definitive treatment options for this disorder are limited. CASE: We present the case of a 32-year-old woman, gravida 1 para 1, with persistent genital arousal disorder after treatment of an uncomplicated urinary tract infection while in a military-deployed environment. After numerous treatment modalities failed, she responded to an implanted sacral neuromodulator. CONCLUSION: Persistent genital arousal disorder may be the result of upregulated sacral nerve pathways. We report the use of sacral neuromodulation using unique program settings, which may be an effective alternative in the treatment of this distressing disorder.

MORTALITY OF SELECTED AVIAN ORDERS SUBMITTED TO A WILDLIFE DIAGNOSTIC LABORATORY (SOUTHEASTERN COOPERATIVE WILDLIFE DISEASE STUDY, USA): A 36-YEAR RETROSPECTIVE ANALYSIS.

To determine the relative importance of mortality factors for birds and to assess for patterns in avian mortality over time, we retrospectively examined data of birds submitted to the Southeastern Cooperative Wildlife Disease Study (SCWDS; http://vet.uga.edu/scwds ), US, from 1976 to 2012. During this period, SCWDS, a wildlife diagnostic laboratory, received 2,583 wild bird specimens, from the taxonomic orders Apodiformes, Caprimulgiformes, Cuculiformes, Passeriformes, and Piciformes, originating from 22 states. Data from 2,001 of these birds were analyzed using log-linear models to explore correlations between causes of mortality, taxonomic family, demography, geographic location, and seasonality. Toxicosis was the major cause of mortality, followed by trauma, bacterial infection, physiologic stress, viral infection, and other (mortality causes with low sample numbers and etiologies inconsistent with established categories). Birds submitted during fall and winter had a higher frequency of parasitic infections, trauma, and toxicoses, whereas birds submitted during the spring and summer were more likely to die of an infectious disease, physiologic stress, or trauma. We noted a decrease in toxicoses concurrent with an increase in bacterial infections and trauma diagnoses after the mid-1990s. Toxicosis was the most commonly diagnosed cause of death among adult birds; the majority of juveniles died from physiologic stress, trauma, or viral infections. Infectious agents were diagnosed more often within the families Cardinalidae and Fringilidae, whereas noninfectious etiologies were the primary diagnoses in the Bombycillidae, Parulidae, Sturnidae, Turdidae, and Icteridae. There are important inherent limitations in the examination of data from diagnostic labs, as submission of cases varies in timing, frequency, location, and species and is often influenced by several factors, including media coverage of high-profile mortality events. Notwithstanding, our data provide a rare opportunity to examine long-term, regional, and temporal patterns in causes of avian mortality, and they allow for the analysis of novel and rare mortality factors.

What is new in the use of mesh in vaginal surgery? Best articles from the past year.

This month we focus on current research in use of mesh in vaginal surgery. Dr. Fischer discusses four recent publications, and each is concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in Box 1 on this page, along with direct links to the abstracts.

Apparent increase of reported hemorrhagic disease in the midwestern and northeastern USA.

We investigated temporal and spatial trends in reporting of hemorrhagic disease (HD) in the midwestern and northeastern US using a 33-yr (1980-2012) questionnaire-based data set. This data set was supported by an additional 19 yr (1994-2012) of bluetongue virus (BTV) and epizootic hemorrhagic disease virus (EHDV) isolation results from clinically affected white-tailed deer (Odocoileus virginianus) in these regions. Both the number of counties that were reported positive for HD and the northern latitudinal range of reported HD increased with time. A similar increase was observed with both the number of states annually reporting HD and the number of counties where HD was reported. Large-scale outbreaks occurred in 1988, 1996, 2007, and 2012, and the scale of these individual outbreaks also increased with time. The predominant virus isolated from these regions was EHDV-2, but the prevalence of EHDV-6, which was first detected in 2006, appears to be increasing. Temporally, the extent of regional HD reporting was correlated with regional drought conditions. The significance of increases in reported HD and the incursions and establishment of new BTV and EHDV in the US currently are unknown.

Experimental feeding of Hydrilla verticillata colonized by stigonematales cyanobacteria induces vacuolar myelinopathy in painted turtles (Chrysemys picta).

Vacuolar myelinopathy (VM) is a neurologic disease primarily found in birds that occurs when wildlife ingest submerged aquatic vegetation colonized by an uncharacterized toxin-producing cyanobacterium (hereafter "UCB" for "uncharacterized cyanobacterium"). Turtles are among the closest extant relatives of birds and many species directly and/or indirectly consume aquatic vegetation. However, it is unknown whether turtles can develop VM. We conducted a feeding trial to determine whether painted turtles (Chrysemys picta) would develop VM after feeding on Hydrilla (Hydrilla verticillata), colonized by the UCB (Hydrilla is the most common "host" of UCB). We hypothesized turtles fed Hydrilla colonized by the UCB would exhibit neurologic impairment and vacuolation of nervous tissues, whereas turtles fed Hydrilla free of the UCB would not. The ability of Hydrilla colonized by the UCB to cause VM (hereafter, "toxicity") was verified by feeding it to domestic chickens (Gallus gallus domesticus) or necropsy of field collected American coots (Fulica americana) captured at the site of Hydrilla collections. We randomly assigned ten wild-caught turtles into toxic or non-toxic Hydrilla feeding groups and delivered the diets for up to 97 days. Between days 82 and 89, all turtles fed toxic Hydrilla displayed physical and/or neurologic impairment. Histologic examination of the brain and spinal cord revealed vacuolations in all treatment turtles. None of the control turtles exhibited neurologic impairment or had detectable brain or spinal cord vacuolations. This is the first evidence that freshwater turtles can become neurologically impaired and develop vacuolations after consuming toxic Hydrilla colonized with the UCB. The southeastern United States, where outbreaks of VM occur regularly and where vegetation colonized by the UCB is common, is also a global hotspot of freshwater turtle diversity. Our results suggest that further investigations into the effect of the putative UCB toxin on wild turtles in situ are warranted.

What is new in obstetric anal sphincter injuries?: Best articles from the past year.

This month, we focus on current research in obstetric anal sphincter injuries. Dr. Fischer discusses four recent publications, and each is concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in on this page, along with direct links to the abstracts.

The epizootiology of anatid herpesvirus 1 infection in free-flying waterfowl: a comparison of latent and active infections among native waterfowl, captive-reared released ducks, and peridomestic or feral ducks.

The epizootiology of anatid herpesvirus 1 (AHV-1) infection in waterfowl is poorly understood but apparently involves persistence of the virus in latently infected birds. Epornitics have often occurred in captive waterfowl or semiwild ducks in parklike settings, and many wildlife professionals conclude that such ducks may be the source of infection for wild waterfowl. We assessed the prevalence of latent infection and viral shedding from four groups of waterfowl: naturally occurring populations of native waterfowl, captive-reared waterfowl released for shooting, introduced nonmigratory waterfowl (e.g., resident, wild Mallards; Anas platyrhynchos), and semiwild peridomestic waterfowl (e.g., park ducks) in North Carolina and Florida, USA from 2004 to 2009. A nested PCR assay was used to detect viral DNA in trigeminal ganglia and cloacal swabs. Detection of viral DNA in trigeminal ganglia, but not cloacal swabs, was assumed to indicate latent infection, whereas PCR-positive cloacal swabs indicated active shedding of the virus. We collected 2,045 samples from 23 species of native, wild waterfowl, and detected latent infections in nine species. Wild Northern Pintails (Anas acuta), a species reportedly resistant to the virus, had the highest prevalence (8.1%). However, low prevalences were identified in other waterfowl from various families. Cloacal shedding was rarely detected (0.1% prevalence) among native waterfowl and was observed in one Blue-winged Teal (Anas discors) and one Mottled Duck (Anas fulvigula). All captive-reared, released waterfowl (n=13) collected were Mallards and one was latently infected, suggesting that these birds could also serve as a source of AHV-1 for naive waterfowl. All nonmigratory waterfowl sampled (n=90) were also Mallards. None of the resident Mallards were shedding virus, but one was latently infected. The peridomestic waterfowl sampled included breeds of domestic Mallard (n=6) and Muscovy Ducks (Cairina moschata; n=73). One peridomestic Mallard and four Muscovy Ducks were shedding virus at the time they were sampled, but no latently infected, asymptomatic carriers were identified.

Surveillance of Wildlife Diseases: Lessons from the West Nile Virus Outbreak.

The West Nile virus outbreak of 1999 revealed many weaknesses in this country's ability to respond to disease threats that cross species lines. There were issues of poor communication among human, domestic animal, and wildlife health agencies that delayed diagnosis; a lack of diagnostic capacity of wildlife agencies at the state level; the exclusion of captive wildlife from any surveillance efforts; an inability to visualize the geospatial relationship between the human and avian outbreaks in a timely manner; and marked disparities of funding levels across agencies. Wildlife has played an important role in recent emerging infectious diseases, and it is clear that a One Health approach will be necessary to respond to future threats. The question is, are we any better prepared to recognize and respond to a wildlife-related emerging infectious disease than we were 14 years ago? Have the lessons of WNV been learned?

Transobturator tape removal using a combined vaginal-transcutaneous approach for intractable groin pain.

BACKGROUND: : Transient groin pain is a therapeutically challenging complication associated with transobturator sling procedures. CASE: : We present the case of a 37-year-old woman who presented with debilitating left groin pain and dyspareunia following placement of transobturator sling. Pelvic floor physical therapy, medications, and trigger point injections failed to provide relief. Workup included magnetic resonance imaging of the pelvis, complex cystometrics, and additional trigger point injections. Surgical removal of the complete left side of the tape including the portion imbedded in the obturator foramen was performed with a combined vaginal-transcutaneous approach. Extirpation of the mesh arm brought prompt and full resolution of the patient's symptoms. CONCLUSIONS: : Surgical removal of the transobturator tape through the obturator foramen can be safely performed using a combined vaginal-transcutaneous approach.

Interposition grafts for rectovaginal fistula repair in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The objective was to use an animal model to study different types of interposition grafts for rectovaginal fistula repair. METHODS: Twelve New Zealand white rabbits underwent surgical creation of a rectovaginal fistula, followed by repair. Four repair techniques were studied; three with interposition grafts and one control group without a graft. Animals were euthanized at 4-week intervals and underwent gross and histologic analysis. RESULTS: The mean rectovaginal wall thickness was greatest in the control group (5.6 mm) and thinnest in the autologous rectus fascia (4.2 mm) and porcine small intestine submucosa (5.1 mm) groups. The polypropylene graft had a mean thickness of 5.4 mm and elicited a strong, protracted inflammatory response. All fistulas were successfully closed except one porcine small intestine submucosa repair. CONCLUSIONS: There is no benefit from interposition graft use for rectovaginal fistula repair in our New Zealand white rabbit model.

Rectovaginal fistula model in the New Zealand white rabbit.

INTRODUCTION AND HYPOTHESIS: The purpose of this study was to create an animal model to study rectovaginal fistula repair. METHODS: Fourteen New Zealand white rabbits underwent surgical creation of a rectovaginal fistula. The technique was developed with a pilot study conducted on the first two animals, then standardized and performed on the remaining 12 rabbits. The standardized technique included making a defect in the rectovaginal septum using a 3-mm skin punch then splinting the defect with 6-mm tubing for 2 weeks. RESULTS: Using the standardized technique, a fistula was successfully created in all 12 rabbits ranging from 1 to 5 mm (mean = 2.8 mm, SD = 1.1). A 95% tolerance interval was calculated for the model and predicted that a successful fistula can be created ranging from 0.3 to 5.2 mm in 85% of attempts with the model. CONCLUSION: The New Zealand white rabbit is a promising animal model to study rectovaginal fistula repair.

Overactive bladder medication adherence when medication is free to patients.

PURPOSE: We examined overactive bladder medication compliance in a health care system in which patients do not pay for medication. MATERIALS AND METHODS: Pharmacy dispensing records were reviewed for antimuscarinic agents from January 2003 to December 2006 for the United States Military Health System National Capital Region. Medication nonpersistence, switching and adherence were examined. Kaplan-Meier survival analysis was done to compare medication persistence duration. RESULTS: Overactive bladder medications were dispensed to 7,879 adults. Tolterodine extended release (4,716 patients or 60%) and oxybutynin immediate release (2,003 or 25.5%) were most commonly prescribed. The medication nonpersistence rate, defined as the proportion of patients who never refilled a prescription for antimuscarinics during the study period, was 35.1% (2,760 of 7,858). Of 5,098 patients who refilled a prescription 1,305 changed the medication or dose at least once for a medication switch rate of 25.6%. The overall median medication possession ratio, defined as the total days of medication dispensed except for the last refill divided by the number of days between the first dispense date and the last refill date, was 0.82 in all cases. Men had a significantly higher median medication possession ratio than women (0.86 vs 0.81, p <0.001). Of patients who obtained at least 1 refill women remained on medication longer than men (median 606 vs 547 days, p = 0.01). Patients on tolterodine extended release had a higher medication nonpersistence rate than those on oxybutynin immediate release (0.89 vs 0.68, p <0.01). There was no difference between extended release medications. CONCLUSIONS: In a health care system in which patients do not pay for medications 35% of patients did not refill a prescription for overactive bladder medication, similar to previous reports. However, other measures of medication compliance were higher than those published previously in systems with copays.

Surveys for disease agents in introduced elk in Arkansas and Kentucky.

Surveys for disease agents were conducted in introduced free-ranging elk (Cervus elaphus nelsoni) in Arkansas and Kentucky. Elk had been captured in Colorado and Nebraska and released in Arkansas during 1981-1985. From 1997 through 2002 elk were captured in Arizona, Kansas, North Dakota, New Mexico, Oregon, and Utah and released in southeastern Kentucky. Specimens were collected from 170 hunter-killed elk in Arkansas during 1998-2006, and 44 elk in Kentucky during 2001-2004. Significant findings included isolation of Mycobacterium avium paratuberculosis from one elk in Kentucky and evidence of previous or current infections by Parelaphostrongylus tenuis in several animals in Arkansas. Serological tests provided evidence of previous infection by epizootic hemorrhagic disease virus, bluetongue virus, bovine viral diarrhea virus, infectious bovine rhinotracheitis virus, parainfluenza-3 virus, and multiple serovars of Leptospira interrogans. Mycobacterium bovis, Brucella abortus, chronic wasting disease (CWD), and hemoparasites such as Anaplasma spp. were not detected. Results from elk obtained through these surveys were consistent with exposure to disease agents endemic in livestock and wildlife in Arkansas and Kentucky.