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  • October 02, 2018 7:24 AM | Anonymous

    October 2, 2018, HealthDay New

    Women plagued by recurrent urinary tract infections (UTIs) may look no farther than their kitchen tap for relief, a new study suggests.

    Researchers found that women who drank plenty of water had a significant reduction in their odds for a recurrence of the common infections.

    "This study provides convincing evidence that increased daily intake of water can reduce frequent UTIs," said lead researcher Dr. Thomas Hooton. He's clinical professor of medicine in the division of infectious diseases at the University of Miami.

    Water appears to work its magic "presumably via the flushing effect of increased urine volume, but there may be other effects we are not aware of," Hooton said in a university news release.

    One specialist in women's health said the UTI-fighting benefits of hydrating with H2O have long been suspected, but not confirmed in a clinical trial until now.

    "Ask anyone who's had even one UTI, they are no fun," said Dr. Jill Rabin, who helps direct Women's Health Services at Northwell Health in New Hyde Park, N.Y.

    "In this study, women were included if they'd had three or more episodes in the prior year -- definitely painful and life-disrupting," noted Rabin, who wasn't involved in the new study.

    "Drinking more water to improve one's health is probably safe and, if tap is used, pretty inexpensive," she added. "Producing additional urine -- and thus increasing voiding frequency -- may raise one's awareness of the importance of keeping the bladder as empty as possible, which can help reduce UTIs."

    The new trial included 140 younger, premenopausal women in Europe who had all experienced high numbers of recurrent UTIs. Their total daily fluid intake at the start of the study totaled less than six 8-ounce glasses per day.

    During the year-long trial, half of the women drank just over six cups more each day of water, in addition to their regular daily fluid intake. Intake remained the same for the other half of women.

    The reduction in UTI frequency for those who drank the additional water was significant. While the average number of UTIs during the study period was 3.2 for women who did not increase their water intake, it fell to 1.7 for those women whose intake rose, the findings showed.

    There was also a significant reduction in antibiotic use among the women who drank more water. Antibiotics are the main treatment of UTIs, and cutting down on the overuse of antibiotics is key to curbing the emergence of microbes resistant to the drugs.

    Hooton said the trial was long overdue.

    "While it's been widely assumed that increased water intake helps to flush out bacteria and reduce the risk of recurrent UTI, there has been no supporting research data showing such a beneficial effect of water," he said.

    The study did not determine the ideal amount of daily water intake to reduce the risk of UTIs, or whether boosting water intake would help women who are at a lower risk of recurrent UTIs than the group chosen for this trial.

    Dr. Elizabeth Kavaler is a urology specialist at Lenox Hill Hospital in New York City. She said the trial highlights the notion that "water is the preferred beverage for overall bladder and kidney health." She added that "the amount that we each need depends on the environment, activity level and diet."

    The study was published online Oct. 1 in JAMA Internal Medicine. It was funded by Danone, Inc., the maker of Evian bottled water.

  • September 27, 2018 8:53 AM | Anonymous

    September 27, 2018, Rockafelleer Unversity via Medical Press 

    Thanks to improvements in antiretroviral therapy, HIV is now a manageable condition. Yet even the best drugs do not entirely eliminate the virus, which latently lingers in the body, threatening to rise to dangerous levels should a patient forget or forgo treatment. To remain healthy, people infected with HIV must therefore adhere to strict medication regimens, which typically involve ingesting pills every day for the rest of their lives.

    New clinical trials from Rockefeller University researchers suggest that a novel immunotherapy, a combination of two anti-HIV antibodies, is capable of suppressing HIV for months at a time. The drugs, called broadly neurtralizing antibodies or bNAbs (pronounced bee-nabbs), were found to be both safe and more effective than any previously tested antibody therapy. The results were published in Nature and Nature Medicine.

    The power of antibodies

    Antiretroviral therapy, the gold standard for HIV treatment, works almost perfectly in . But in the real world, things are more complicated. Some patients neglect to take their meds, or lose access to healthcare. And inconsistency in treatment presents a risk not only to the person infected, but to the population at large: when the  is not adequately controlled, the likelihood of transmission increases.

    To protect both individuals and communities, researchers are hoping to develop drugs that don't rely on vigilant daily dosing. The results of the new studies, led by Michel C. Nussenzweig, Marina Caskey, and their colleagues, suggest that such a medication may in fact be on the horizon.

    Nussenzweig, the Zanvil A. Cohn and Ralph M. Steinman Professor, initially identified the antibodies, known as 3BNC117 and 10-1074, while studying people whose bodies successfully combat HIV without the help of drugs. In these so-called "elite controllers," natural antibodies target proteins on the outside of the virus and recruit the body's immune system to combat infection.

    The ultimate goal of bNAb therapy is to turn anyone taking the medication into an elite controller, effectively suppressing the virus through an enhanced immune response. These drugs have the added benefit of remaining in the body longer than , and therefore should require less frequent administration.

    Previous studies have shown that treatment with a single bNAb reduces the levels of virus in the blood, but these effects are short-lived. Over time, HIV mutates in such a way that the antibody can no longer find and fight the virus.

    Because 3BNC117 and 10-1074 attack HIV from two different angles, the researchers suspected that administering the two drugs together might evade resistance—an approach first tested in animals. Following the success of these initial experiments, Nussenzweig and Caskey, an associate professor of clinical investigation, adapted the treatment for use in humans.

    In their phase 1b clinical trial, published in Nature, participants stopped taking antiretroviral drugs and subsequently received three infusions of the two bNAbs over the course of six weeks. The researchers report that, among nine individuals who carried viruses that were sensitive to both antibodies, this treatment suppressed HIV for an average of 21 weeks, and over 30 weeks in some patients. Unlike individuals receiving only one bNAb, those receiving combination therapy did not develop resistance if their viruses were sensitive to the antibodies. Moreover, participants experienced no major side effects, the most significant reaction being mild fatigue in a small portion of patients.

    Participants entering this first trial were not viremic—meaning, HIV was not actively circulating in their bloodstream because antiretroviral drugs had brought the virus to very low or undetectable levels. The second study, published in Nature Medicine, showed that bNAbs were also effective in treating viremic patients; in this case, combination therapy reduced virus levels for up to three months.

    The future of bNAbs

    Caskey and Nussenzweig say that although  is very promising, bNAb treatments do have their limitations. The HIV virus comes in many varieties, not all of which respond to a given antibody.

    "These two antibodies are not going to work for everyone," says Caskey. "But if we start to combine this therapy with other antibodies or with antiretroviral drugs, it could be effective in more people—and that's something we hope to look at in future studies."

    Nussenzweig adds that, over time, bNAb therapy could prompt the body to produce HIV-fighting antibodies on its own. "Like some anti-cancer antibodies, these drugs could interact with the host immune system to boost natural immunity," he says.

    Further research might also lengthen the amount of time for which these drugs are effective. The studies showed that bNAbs can control HIV for more than four months in some people—an impressively long suppression period. Still, Nussenzweig suspects that this period could be extended yet further through the use of newly-developed bNAb variants.

    "The expectation is that these new variants will have three- to four-fold longer half-lives," he says. "So we may be able to give the  once or twice a year."

    The researchers believe that bNAbs have the potential to change not only how we treat HIV, but also how we prevent it. Currently, people at risk for contracting the virus can take preemptive antiretroviral medication. But that too requires daily dosing, and many people follow the regimen imperfectly. Like long-acting birth control, long-acting HIV medication would allow people to achieve the desired outcome without being perfect pill takers.

    "If future studies are similarly successful, bNAbs could really become a practical alternative to ART," says Caskey, "an alternative that would be safe and wouldn't require a pill every day."

    More information: Pilar Mendoza et al, Combination therapy with anti-HIV-1 antibodies maintains viral suppression, Nature (2018). DOI: 10.1038/s41586-018-0531-2

  • September 24, 2018 10:00 AM | Anonymous

    September 25, 2018, Medscape 

    Obesity almost doubles the risk for urinary incontinence (UI) in young and middle-aged women compared with women of normal weight, the authors of a new meta-analysis warn.

    These findings are significant because those with a history of even mild UI when young are more likely than women without such a history to have increasingly bothersome symptoms as they grow older, and the longer they have the excess weight, the greater the risk for UI, lead author Tayla Lamerton, a PhD candidate in women's health at the University of Queensland, Brisbane, Australia, and colleagues write.

    The study was published online September 19 in Obesity Reviews.

    Once considered a condition of mostly older or multiparous women, UI, defined as the involuntary loss of urine, has become increasingly prevalent in younger and nulliparous women, leading to a search for causes, Lamerton and colleagues explain. Recent research suggests that overweight and obesity may increase the risk for UI in women, possibly because excess abdominal weight places increased pressure on the bladder, which may, in turn, exceed urethral closure pressure leading to urine leakage.

    They suggest that clinicians "emphasize the role of excess weight on pelvic floor weakening and subsequent risk for incontinence" along with its metabolic risks. In fact, maintenance of a healthy weight could be presented to younger women as a strategy for preventing UI.

    The data support a new clinical guideline from the US Women's Preventive Services Initiative that recommends all women, even adolescents, be screened for UI once a year, although not all experts agree with this recommendation.

    Excess Weight Overshadows Age as a Risk Factor for UI

    In their study, Lamerton and coauthors searched for articles published in English up until September 2017. Inclusion parameters were cohorts with a mean age of 55 years or younger at baseline; excess weight measured using body mass index (BMI), weight, or waist circumference; follow-up of more than 2 years; and use of a risk ratio (RR) estimate of the association between excess weight and UI, among other criteria.

    The final analysis included 14 studies with 47,293 women from eight countries: Australia, France, United States, Denmark, England, Scotland, Wales, and the Netherlands. Most participants came from a single study with a sample size of 30,982.

    Among women who were overweight, defined as a BMI of 25 to 30 kg/m2, the risk for UI was increased by about a third compared with women with a normal BMI (pooled risk estimate, 1.35; 95% CI, 1.20 - 1.53). For women who were obese, defined as a BMI > 30 kg/m2, the pooled risk estimate was 1.95 (95% CI, 1.58 - 2.42), again compared with normal-weight women.

    "Overall," the authors write, "the pooled estimate of the risk for developing UI because of excess weight exposure (overweight plus obesity) was 1.68 (95% CI, 1.47 - 1.92)."

    They did not observe any differences in UI risk between women younger than 36 years of age and those aged 36 to 53 years.

    "This result points to the importance of excess weight, above and beyond age-related risk," they add.

    The authors also determined whether excess weight was associated with an increased risk for any of the four subtypes of UI:

    • Stress UI: Involuntary loss of urine associated with activities such as coughing or sneezing;
    • Urge UI: Urinary leakage associated with or immediately preceded by a feeling of urgency;
    • Mixed UI: A combination of urge and stress UI symptoms; and
    • Severe UI: Urinary leakage of unusually high frequency or amount.

    Of the 14 studies included in the analysis, five provided risk estimates according to these subtypes. In a pooled risk estimate, the risk for mixed UI was 2.45, followed by 2.28 for severe UI, 1.90 for urge UI, and 1.83 for stress UI. These differences were not significant.

    In an overall estimate that combined all subtypes, "excess weight doubled the risk of developing any UI subtype," with an effect size of 2.0 (95% CI, 1.74 - 2.31).

    One major limitation was that only five of the studies adjusted for whether women had ever given birth, meaning the risk estimates may not have been completely independent of parity, the authors write.

    Also, none of the studies categorized participants according to subcategories of obesity, so estimation of UI risk according to severity of obesity was not possible. Also, the analysis was limited to studies published in English and conducted in high-income Western nations.

    UI is a complex issue, especially among younger women, Lamerton said in a news release about the study.

    "Understanding overweight and obesity as a determinant of urinary incontinence could play a role in the way we counsel those affected by the condition, and our findings provide a building block to further explore lifestyle interventions for preventing and managing incontinence," she stressed.

    The authors have reported no relevant financial relationships.

    Obesity Reviews. Published online September 19, 2018. Abstract

  • September 24, 2018 9:58 AM | Anonymous

    September 25, 2018, HealthDay News  

    Molecular markers of breast cancer tumors can be identified by focusing on parameters of a cell's nucleus, and aided by machine learning, according to a study published online Sept. 4 in npj Breast Cancer.

    Rishi R. Rawat, from the University of Southern California in Los Angeles, and colleagues introduced a machine learning framework to identify relationships between cancer tissue morphology and hormone receptor pathway activation in breast cancer pathology samples stained with hematoxylin and eosin (H&E). The authors focused on predicting clinical estrogen receptor (ER) status from the spatial arrangement of nuclear features as a proof-of-concept. To predict ER status, the learning pipeline extracted parameters describing the position, shape, and orientation of the nuclei from H&E images, and passed them to a deep neural network.

    The researchers found that the pipeline predicted ER status in an independent test set of 56 patient samples after training on 57 tissue cores of invasive ductal carcinoma (area under the receiver operator characteristic curve, 0.72). Machine-derived descriptors of morphologic histology patterns were correlated to signaling pathway status.

    "We can use this technology to identify the molecular markers of the tumor and in the future will identify which therapeutics the tumor will respond to," Rawat said in a statement. "Machine learning helps us get this information to patients sooner and may transform cancer care in the developing world where precise breast cancer marker assessment is in short supply."

    Abstract/Full Text (subscription or payment may be required)

  • September 21, 2018 7:40 AM | Anonymous

    September 21, 2018, HealthDay News  

    Risk of cardiotoxicity is higher for patients receiving trastuzumab and/or anthracyclines for the treatment of breast cancer, according to a study published in the Aug. 1 issue of JACC: Cardiovascular Imaging.

    Mariana L. Henry, from the University of Texas MD Anderson Cancer Center in Houston, and colleagues used data from the Truven Health MarketScan (IBM Watson Health, Cambridge, Mass.) database to assess the rate of chemotherapy-related cardiotoxicity and to estimate adherence to recommendations for cardiac monitoring among 16,456 breast cancer patients (median age, 56 years) treated with chemotherapy (2009 to 2014).

    The researchers found that cardiotoxicity was identified in 4.2 percent of patients. There was an increased risk of cardiotoxicity associated with therapy with trastuzumab (hazard ratio, 2.01) and anthracyclines (hazard ratio, 1.53), Deyo comorbidity scores (hazard ratios, 1.38 for scores of 1 and 2.47 for scores ≥2), hypertension (hazard ratio, 1.28), and valve disease (hazard ratio, 1.93). Younger patients (≤35 years of age and 36 to 49 years) had lower risk of cardiotoxicity versus patients ≥65 years (hazard ratios, 0.37 and 0.49, respectively). Guideline-adherent cardiac monitoring was identified in 46.2 percent of patients treated with trastuzumab.

    "Cardiac monitoring among trastuzumab-treated patients should be a priority among high-risk patients and in the presence of comorbidities or other chemotherapies such as those using anthracyclines," the authors write.

    One author disclosed financial ties to the pharmaceutical industry.

  • September 12, 2018 9:20 AM | Anonymous

    Women's Health Update 2018 
    Presented by Essential Access Health & Contraceptive Technology   

    October 24-25, 2018, Los Angeles, CA 

    REGISTER TODAY to attend Women's Health Update 2018, including hands-on clinical training sessions on the latest methods and techniques for contraceptive care. The clinical trainings will be provided by nationally recognized experts in the field. Learn more.

  • September 07, 2018 8:27 AM | Anonymous

    Offered via the Association of Reproductive Health Professionals (ARHP)  


    According to the CDC, in 2015, there were an estimated 38,500 new HIV infections, down from 41,800 in 2010. While great progress has been made in preventing and treating HIV, there is still much work to be done. This two-webinar series examines clinical providers’ vital role in HIV prevention.  

    Webinar 1:

    HIV Prevention: Frontline Providers' Role in

    "Getting to Zero"

    September 25th at 4pm EDT

    After this webinar, you will be able to:

    • Summarize current epidemiology of HIV in the U.S.
    • Describe three national frameworks for preventing new HIV infections
    • Summarize current guidelines for HIV screening
    • Explain the current guidelines for initiation of antiretroviral treatment for people living with HIV
    • Apply guidelines and patient-centered communication techniques to a case study 

    Webinar 2:

    HIV Prevention in the Clinical Setting

    November 1st at 2pm EDT

    After this webinar, you will be able to:

    • Summarize current epidemiology of HIV in the U.S.
    • Explain current guidelines for HIV screening
    • Describe current guidelines for initiation of treatment for people who test positive
    • Describe the role of pre-exposure prophylaxis (PrEP) in HIV prevention
    • Apply guidelines and patient-centered communication techniques to a case study 

  • September 04, 2018 9:50 AM | Anonymous
    September 4, 2018, Medscape 

    The US Food and Drug Administration (FDA) has approved two new oral treatments for adults with HIV-1 infection, Pifeltro and Delstrigo, both from Merck & Co, according to a company news release.

    Pifeltro contains doravirine (100 mg), a new non-nucleoside reverse transcriptase inhibitor to be given in combination with other antiretroviral medicines.  Delstrigo is a once-daily fixed-dose combination of doravirine (100 mg), lamivudine (3TC; 300 mg), and tenofovir disoproxil fumarate (TDF; 300 mg).

    Both drugs are indicated for the treatment of HIV-1 infection in adults with no prior antiretroviral treatment history and are taken once daily with or without food.

    The FDA approved doravirine on the basis of the phase 3 DRIVE-FORWARD clinical trial, in which 766 patients with no antiretroviral treatment history were randomly assigned to once-daily treatment with doravirine or darunavir 800 mg plus ritonavir 100 mg (DRV+r), each in combination with emtricitabine (FTC)/TDF or abacavir (ABC)/3TC.

    Treatment with doravirine led to sustained viral suppression through 48 weeks, meeting its primary endpoint of noninferiority compared with DRV+r, each in combination with FTC/TDF or ABC/3TC.

    At week 48, 84% of the doravirine group and 80% of the DRV+r group had plasma HIV-1 RNA of less than 50 copies/mL.

    Of the 20% of study participants with a high viral load at baseline (HIV-1 RNA > 100,000 copies/mL), 77% in the doravirine group and 74% in the DRV+r group achieved HIV-1 RNA of less than 50 copies/mL at week 48.

    The rate of therapy discontinuation due to adverse events was low in both groups (2% in the doravirine group and 3% in the DRV+r group). Clinical adverse reactions of all grades occurring in at least 5% of participants in the doravirine group included nausea (7%), headache (6%), fatigue (6%), diarrhea (5%), and abdominal pain (5%). No adverse reactions of grade 2 or higher occurred in 2% or more of participants treated with doravirine.

    The doravirine/3TC/TDF combination pill was approved on the basis of data from the phase 3 DRIVE-AHEAD trial, in which 728 patients naive to antiretroviral therapy were randomly assigned to once-daily treatment with doravirine/3TC/TDF or efavirenz (EFV)/emtricitabine/tenofovir disoproxil fumarate (EFV 600 mg/FTC 200 mg/TDF 300 mg).

    The doravirine/3TC/TDF combination provided sustained viral suppression through 48 weeks, meeting its primary endpoint of noninferiority compared with EFV/FTC/TDF.

    At week 48, 84% of the doravirine/3TC/TDF group had plasma HIV-1 RNA of less than 50 copies/mL, as did 81% of the EFV/FTC/TDF group.

    Of the 21% of patients with a high viral load at baseline (HIV-1 RNA > 100,000 copies/mL), 77% in the doravirine/3TC/TDF group and 72% in the EFV/FTC/TDF group achieved HIV-1 RNA of less than 50 copies/mL at week 48.

    A statistically significantly lower proportion of doravirine-treated patients reported neuropsychiatric adverse events in the three prespecified categories of dizziness (9% vs 37%), sleep disorders and disturbances (12% vs 26%), and altered sensorium (4% vs. 8%).

    The rate of discontinuation of treatment due to adverse events was lower with doravirine/3TC/TDF than with EFV/FTC/TDF (3% vs 6%). Clinical adverse reactions of all grades occurring in at least 5% of patients in the doravirine group included dizziness (7%), nausea (5%), and abnormal dreams (5%). No adverse reactions of grade 2 or higher occurred in 2% or more of patients treated with doravirine.

    Both of the new drugs "are contraindicated when co-administered with drugs that are strong cytochrome P450 (CYP)3A enzyme inducers as significant decreases in doravirine plasma concentrations may occur, which may decrease the effectiveness of Delstrigo and Pifeltro. Delstrigo is contraindicated in patients with a previous hypersensitivity reaction to 3TC," the company said in its news release.

    "As a result of the remarkable strides made in the fight against HIV, clinicians and their patients have the opportunity to work together to identify treatment regimens that may be best for each individual, taking into account other aspects of that person's health, including other medicines they may be taking," David Wohl, MD, from the AIDS Clinical Trials Unit at the University of North Carolina at Chapel Hill, said in the release. "Today's approvals of Delstrigo and Pifeltro provide two new options for the treatment of HIV-1 in appropriate treatment-naive adult patients."

    Merck said it anticipates that both drugs will be stocked through wholesalers within 1 month.

  • August 30, 2018 2:07 PM | Anonymous

    August 30, 2018, MedPage Today 

    Sexually transmitted disease (STD) diagnoses have increased every year since 2013, with the number of new STD diagnoses the highest ever in 2017, CDC researchers found.

    There were 2.3 million cases of chlamydia, gonorrhea, and syphilis diagnosed in 2017, with syphilis diagnoses up by 76% and gonorrhea diagnoses up by 67% since 2013, according to preliminary data released by the CDC at the National STD Prevention Conference in Washington.

    At a press briefing, Gail Bolan, MD, director of the CDC division of STD prevention, characterized this as a "continuation of a persistent and troubling trend," particularly noting that rates of diagnosis for gonorrhea "nearly doubled" among men and increased one-fifth among women, "something we haven't seen in a long time," she added.

    The CDC reported that chlamydia remained the most common condition reported to the CDC, with more than 1.7 million cases diagnosed in 2017, with a little under half among women ages 15 to 24.

    Bolan cited another troubling statistic about the looming threat of antibiotic resistance regarding gonorrhea treatment. The CDC currently recommends a two-dose therapy for gonorrhea consisting of an intramuscular dose of ceftriaxone -- the only "highly effective" antibiotic used to treat gonorrhea in the U.S. -- and oral azithromycin.

    But Bolan reported that a "small, but growing fraction" of lab specimens of gonorrhea are showing "signs of antibiotic resistance." While she added that there has never been a "confirmed treatment failure" when using this recommended treatment, the worry is there may eventually be a strain of gonorrhea that does not respond to ceftriaxone.

    "Our nation urgently needs new treatment options for gonorrhea," Bolan said. "But CDC alone cannot turn the tide on rising STDs. It requires new commitment from the healthcare sector, scientists, industry, state and local health departments."

    "Commitment" usually means "money," and state and local health officials spoke candidly about the country's "eroding public health infrastructure" that they felt contributed to the tremendous increase in STDs. Specifically, officials cited years of cutbacks in funding for STD prevention, with state and local health departments who rely on federal funding to support their STD programs, working with budgets that are half of what they were 15 years ago.

    "We maintain our bridges and roads, and we see them on TV when they crumble. You don't always see a crumbling public health infrastructure," said Michael Fraser, PhD, executive director, Association of State and Territorial Health Officials (ASTHO). "We know what works with STD prevention. We just don't want to pay for all of it."

    David C. Harvey, MSW, executive director, National Coalition of STD Directors, called for an additional $70 million in funding to "immediately arm state and local health programs to combat this crisis." He said that treatment for STDs costs more than $16 billion a year.

    "It is time that President Trump and Secretary Azar declare STDs in America a public health crisis," adding that emergency access to funding is also needed to bring these rates down.

    In addition to cutbacks in federal and state funding, Harvey cited other factors for the rise of STDs in America, namely the "extreme lack of awareness and education about STDs and sexual health." But he also said providers and patients played a significant role as "doctors are not screening and testing for STDs and patients don't know they need to ask for screening and treatment."

    Bolan added that screening needs to be "routine care" and that providers and patients need to be having that conversation about testing.

    Harvey added a plea to Congress for more funding for provider training, through the CDC STD Prevention Training Centers, where funding has also been cut over the last 20 years.

    But Fraser pointed out that the solution to the rising STD problem is not going to be "treating our way out of it," and that a solid public health infrastructure is also needed. He specifically noted that cuts in funding have affected programs that support "disease investigators," who meet with individuals, talk about their sexual behavior, do contact tracing, and try to prevent future infections.

    "Expecting a physician in an already hurried day-to-day practice to do a slew of [recommended STD testing] is probably not realistic, given the way physicians practice," he said. "Public health can take some of the pressure off the clinical system. You don't need a medical degree to prevent an STD -- you need to talk with people about using condoms."

    Bolan said that the full 2017 STD surveillance report is expected to be released in late September.

  • August 29, 2018 9:00 AM | Anonymous

    APAOG members may view recorded webinars at anytime. Please check out our latest addition, "When Sex Hurts: Identifying and Treating the Causes of Sexual Pain: presented by Alyse Kelly-Jones, MD.

    Click here to view the webinar library. *Must be logged in to view webinar library. 

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