• Introduction: Preeclampsia during pregnancy warrants therapy with low dose aspirin. The purpose of this review is to investigate if these women are at increased future risk for cardiovascular morbidity and mortality, and if aspirin therapy prevents future cardiovascular events.
• Research Questions: Do women who had preeclampsia during pregnancy have increased future cardiovascular morbidity and mortality? • Does continued aspirin use in postpartum women, who had preeclampsia during pregnancy; decrease future cardiovascular morbidity and mortality?
• Research Methods: Literature review was conducted utilizing CINAHL, Dynamed plus and PubMed databases.
• Discussion: Many studies have found that preeclampsia does increase risk of cardiovascular morbidity and mortality, but this difference is not statistically significant until later decades in life. There is also new evidence that the risks of bleeding from prophylactic aspirin therapy outweigh the benefit of decreasing cardiovascular and ischemic events. Based on this information, it is prudent to further research and study this group and stratify their risk as well as researching if there is a better modality upon which to provide prophylaxis with lower risk than benefit.
Catherine M. Bopp
The purpose of this research and systematic literature review is to determine which pharmacotherapeutic agent, methadone or buprenorphine, leads to better outcomes in cases of pregnant mothers with opioid use disorder (OUD). Outcomes considered are maternal compliance, neonatal abstinence syndrome severity, and neonatal length of hospital stay. In the review, PubMed, Clinical Key, Cochrane Database of Systematic Reviews, and DynaMed Plus were searched. Key terms searched were “methadone, buprenorphine, pregnancy”, “opioids, pregnancy”, “neonatal abstinence syndrome” and “medication assisted treatment, pregnancy”. Several studies were excluded, as their study population was not specified to have diagnosed OUD in pregnancy. The drawbacks to many of the studies is the inconsistencies in study conditions, and very small sample sizes. Much of the research presented shows evidence for the use of buprenorphine in the treatment of OUD in pregnancy. Buprenorphine seems to be a better medication assisted treatment (MAT) for the neonate in terms of reduced neonatal abstinence syndrome (NAS) and reduced length of hospital stay postpartum, while methadone still performs better for adherence for the mother. More research still needs to be done in order to demonstrate buprenorphine’s superior efficacy compared to methadone use in pregnant patients with OUD.
With the high incidence of Lyme disease in the endemic areas of North America, it is important to appropriately diagnosis and treat this condition to prevent post treatment Lyme disease syndrome (PTLDS). Background information regarding Lyme disease is given. The purpose of this research is to discuss the treatment options available for those patients that fit the case definition of PTLDS. A literature review was conducted using several different electronic databases finding peer reviewed research articles pertaining to the treatment options available for PTLDS. Extended antibiotic use is shown to be not beneficial in most cases. Alternative treatment options listed on the internet are shown to be not evidence based. Therefore, symptomatic treatment options seem to be the best positive outcome-based option available for providers to use. These options are discussed in detail throughout this research. Though much more research is needed regarding the topic, this will give providers the information currently available that they will need to know when treating patients with PTLDS. Hopefully this will provide the patients with PTLDS the best outcome possible for improving their quality of life post Lyme disease.
Fertility Options for Women with Endometriosis: In Vitro Fertilization versus Surgical Excision or Ablation
Endometriosis negatively affects the fertility of many women of reproductive age worldwide. Some women with endometriosis are able to conceive without reproduction assistance, while others require medical intervention. In vitro fertilization and surgical management are available and widely used in the treatment of endometriosis associated infertility. In vitro fertilization has been found to be effective in women with stages I-IV endometriosis, with varying degrees of success at each stage. These varying results may be due to oocyte quality and availability as well as endometriosis location. Surgical excision and/or surgical ablation of endometriosis/endometriomas may also improve chance of successful pregnancy but has been found to decrease ovarian reserve and therefore decrease future fertility as a result of ovarian damage and decreased ovarian reserve. This project will discuss surgical treatment of endometriosis and in vitro fertilization in patients with endometriosis and the result of each on achieving and maintaining pregnancy.
• Obesity is a rising epidemic, and is one of the most common, costly and preventable health problems the world is experiencing today (Center for Disease Control and Prevention, [CDC], 2017).
• From this, it is important to establish an effective treatment plan that can be implemented across the nation for maximum patient benefit.
• Lifestyle changes such as diet and exercise are important to any health care plan and are equally necessary to reduce health risks. However, in certain patients, lifestyle changes are not enough due to the maladaptive biologic process in their brain. Thus, additional treatment options need to be available to these patients.
• Both medical therapies, pharmacological and surgical, were found to be beneficial in augmenting lifestyle changes in multiple studies. Therefore, it was concluded that pharmacologic and surgical therapies are valid options in resistant obesity in addition to lifestyle changes such as diet and exercise.
• This study was a systematic literature review which evaluated studies from CINAHL, Clinical Key, Cochrane Library, and PubMed to formulate a conclusion. Research focused on two pharmacotherapy options, phentermine and orlistat, in addition to two surgical options, gastric bypass and sleeve gastrectomy, for added weight loss treatment when compared to lifestyle alone.
Sexually transmitted infections (STI) such as Neisseria Gonorrhoeae and Chlamydia Trachomatis pose a challenge to the healthcare system worldwide. Treating sexual partners is as crucial to controlling the spread of these infections as treating index patients. However, because of problems associated with stigma, reaching affected populations, and ensuring follow-up, unique solutions are require to ensure partners receive treatment. One solution is Expedited Partner Therapy (EPT). EPT refers to treating patients, and providing necessary medication for both patient and partner. Current recommendations are for oral doses one gram of azithromycin and 400 milligrams of cefixime. This literature review looked at thirteen studies, and aimed to determine whether EPT is still superior to standard partner notification at reducing further infection, and reinfection in adult Gonorrhea and Chlamydia (GC) patients in the US. Research indicates that EPT remains a viable, cost- effective measure at controlling the spread of GC infections. EPT appears to be the best available option despite use of second-line treatments in resistance-prone infections. Additionally, there is a need for future, large- scale, US-based randomized controlled trials to unequivocally show the continued effectiveness of EPT.
There is discrepancy amongst organizations and the medical community whether bimanual pelvic examinations should be performed in asymptomatic women for routine screening. The purpose of this literature review was to determine whether bimanual pelvic examinations are beneficial for screening for ovarian cancer in comparison to no screening. In addition, research was conducted to see if healthcare providers’ professional beliefs align with the evidence and national recommendations, to determine women’s thoughts and beliefs regarding pelvic examinations, and identify other screening methods if bimanual pelvic exams are determined to be an invalid screening tool. Throughout reviewing peer reviewed articles and high-quality evidence, it was found that bimanual pelvic exams have low sensitivity for screening, which is not ideal due to false positives; however, several researchers still feel this is an important screening tool. Also, many providers still consider the pelvic exam beneficial when performed annually on asymptomatic women as part of a well-woman exam and continue to perform them routinely in the office. Research also shows that the majority of women do not feel uncomfortable or pain during a pelvic exam and the majority wish to continue having them performed on a regular basis. Combinations of different screening methods such as pelvic examination with serum CA-125 annually and serum CA-125 with transvaginal ultrasound annually were found to be effective in screening for ovarian cancer in asymptomatic women.
Carl David Eastep
• The opioid crisis dictates the need for research into alternative treatments for acute and chronic pain.
• Comprehensive literature review was conducted to determine if medical marijuana might play a role in the treatment of acute and chronic pain.
• The addiction profiles of medical marijuana and prescription opiates were compared along with the adverse effects and quality of life.
• No use for medical marijuana for the treatment of acute pain.
• Likely some benefits from medical marijuana for chronic pain.
• Addictive profile
• Marijuana – marijuana withdrawal syndrome.
• Prescription Opiates – highly addictive
• Adverse Effects
• Prescription Opiates > Marijuana
Obesity is associated with a variety of medical conditions that adversely affect metabolic and cardiovascular health. In order for health care providers to adequately educate and promote weight management, they need to be aware of the various dietary regimens and the efficacy and adverse effects associated with each. This literature review assesses the efficacy, metabolic benefits, and cardiovascular benefits of both intermittent energy restriction and continuous energy restriction from ten articles found on various databases within the past five years. The findings indicate that although not proven superior or inferior, intermittent energy restriction provides statistically similar results to continuous energy restriction when assessing efficacy of weight loss. There are also similar metabolic and cardiovascular benefits when comparing intermittent energy restriction and continuous energy restriction, although continuous energy restriction may have a benefit in the diabetic population due to potential adverse side effects in diabetics adhering to intermittent energy restriction. The result of this literature review allows providers to recommend an alternative weight management technique in patients who are unsuccessful or unable to adhere to a continuous energy restriction diet.
Embolus Prevention: Anticoagulant Therapy in Comparison to Watchman's Procedure in Patients with Atrial Fibrillation
• Atrial fibrillation or A-fib is a common cardiac disease that occurs as individuals get older.
• A risk factor of atrial fibrillation is blood clot formation and dislodgement or ‘embolus’ in the left atrium.
• Current treatment methods to prevent clot formation include anticoagulants, as well as a left atrial appendage closure device, The Watchman’s device is the only FDA approved left atrial appendage closure device.
• Study results confirm the rising efficacy and cost effectiveness of Watchman’s device versus long term anticoagulant therapy as well as their adverse effects regarding placement and post procedure; however further randomized control trials are needed to compare both therapies particularly novel oral anticoagulants head to head rather than through extrapolation.
• Long term effects of Watchman’s device need to be studied.
Major Depressive Disorder (MDD) is a common disease seen every day by primary care providers across the United States. According to the Centers for Disease Control and Prevention (CDC, 2018), eight percent of all adults over the age of 20 suffer from depression, and a study by the American Psychological Association found depressive disorders to cost roughly $71 billion annually. Today, psychotherapy is the recommended first-line therapy for treating MDD, but pharmacotherapy is more commonly used. Alternative forms of therapy are also being researched in order to avoid the use of medication while adequately treating the symptoms of MDD. For this review, seven databases were searched including PubMed, Cochrane Database of Systematic Reviews, PsycInfo, Cinahl, DynaMed, ClinicalKey, and ScienceDirect from September 1 to November 21, 2018. Works chosen for review were published after the year 2000 and included randomized controlled trials (RCTs), systematic reviews, and meta analyses. This review found several benefits of using exercise to treat MDD while reducing risks, but exercise alone is not superior in effectiveness to psychotherapy or pharmacotherapy. Overall, exercise offers the greatest benefit in reducing MDD symptoms when used as an augmented therapy to either psychotherapy or pharmacotherapy. Limitations of this literature review include lack of studies with longevity or large sample sizes.
Stephanie M. Gagelin
• Many of today’s industries require workers to perform shift work (typically during 1600-0700). If workers are awake during this time period, circadian misalignment occurs. This scholarly project uses research studies and meta- analyses to provide information about increased health risks associated with circadian misalignment, focusing on the categories of glucose metabolism, cardiovascular system, carcinogenesis, and mental health and acuity.
• Shift work has been found to increase BMI and waist circumference of employees, as well as increase blood glucose levels to “prediabetic” levels in previously euglycemic individuals.
• Shift work has been proven to increase high-sensitivity C-reactive protein (hs-CRP), an acute phase reactant that indicates inflammation and has been found to be a precursor to cardiovascular disease. Additionally, shift work has been demonstrated to increase risk for several cardiovascular diseases, including myocardial infarction and ischemic stroke.
• Men who work shift work are at higher risk for developing prostate cancer, and women who have performed shift work for over 30 years are at increased risk for breast cancer development.
• Working a night shift job and its associated sleep deprivation was proven to make medical interns more susceptible to developing depression, as well as more likely to make medical errors due to their sleep deprivation.
Juan Carlos Garcia Ramirez
• Uncompensated health care and Emergency Department (ED) overcrowding are a national crisis in the United States, and uninsured patients are a major contributor. Undocumented Immigrants (UIs) are a large component of the uninsured patient population.
• The purpose of this study is to evaluate for efficacy and taxpayer value two large-scale potential solutions: Federally Qualified Health Centers (FQHCs), and expanded Medicaid.
• The method of research included a variety of key terms in electronic search databases such as CINAHL Complete, PubMed, and Google Scholar, and only articles published between 2014 and 2018 by peer- reviewed journals or gray literature (.gov) were included.
• A Limitation of this study was the inability to conduct a single or limited number of systematic searches of related studies or articles and filter the results using a prescribed set of inclusion or exclusion criteria.
• Data results suggest that while expanded Medicaid does reduce uncompensated health care, it has been shown to increase ED use and overcrowding, at least in the short-term. Therefore, the notion that expanded Medicaid successfully reduces ED overcrowding, was found to be false. FQHCs are a reasonable solution, but there are too few, and relatively unheard of among the target population.
Philip J. Heiden
The purpose of this systematic literature review is to determine the efficacy and safety of rivaroxaban (Xarelto) compared to warfarin (Coumadin), for the long term prophylaxis of recurrent venous thromboembolism (VTE). Rivaroxaban was chosen as the primary representative of factor Xa inhibitors because of its simplistic once a day dosing regimen. The PubMed database was extensively searched, using a variety of key terms, from September 10 to November 30, 2018. Works chosen include propensity-matched cohorts, retrospective studies, systematic reviews, and meta-analyses. All of which were published within the last 10 years; sources dated prior to 10 years were excluded. Studies with poor design or dual antiplatelet therapies were also grounds for exclusion. For this review, 11 resources were selected for analysis; 7 additional resources were included for contextual information. Much of the research revealed that rivaroxaban is an adequate alternative for VTE prophylaxis, but the purpose of this research was to determine if its efficacy and safety is superior to that of warfarin. Despite statistically superior results for several aspects of rivaroxaban, an absence of distinct recommendations remain. The following results are intended to make the difficult decision of choosing an anticoagulant clearer for medical professionals and patients.
Sepsis kills nearly 1 million people each year in the United States and sepsis-related hospitalizations cost approximately $24 billion annually (Paoli, Reynolds, Sinha, Gitlin, & Crouser, 2018). Current treatment guidelines are limited to targeted antibiotics and hemodynamic support. While antibiotics are the definitive treatment to eradicate the infectious pathogen, there are currently no standard-of-care treatments that consistently and successfully attenuate the damage sustained to the body by its own inflammatory response to infection. Many different treatments have been trialed and failed to show improved outcomes. Vitamin C, or ascorbic acid, has long been associated with supporting immune function, and has been studied in the past in various related capacities. More recently, a study initiated by Dr. Paul Marik has spurred much discussion and additional research regarding the potential use of ascorbic acid as an adjunctive treatment for sepsis patients. Research suggests that it may reduce damage by reducing oxidative stress, regulate the body’s immune response, and facilitating the production of endogenous vasopressin. Discussion will include the mechanism of action of ascorbic acid in the body, its potential role, efficacy, and safety in the treatment of sepsis, as well as additional treatment components. Also discussed is the cost in both dollars and mortality, of waiting to implement the widespread use of what appears in some studies to be a low-cost, low-risk, high- reward treatment.
• The goal of this scholarly project was to evaluate the efficacy of pharmacogenomic testing (PGx) versus treatment as usual (TAU) in the treatment of major depressive disorder (MDD). According to Huang & Lin (2015), MDD is characterized by multiple signs and symptoms consisting of mood, vegetative, cognitive, and even psychotic behaviors that may cause substantial impairment in the functioning and quality of life in an affected individual. This literature review consisted of articles found in PubMed, Cochrane, and PsychINFO which were extensively reviewed. Articles prior to 2008 were excluded due to the ever-changing landscape of PGx testing. In this review, 18 articles and studies were analyzed. This review found favorable outcomes when treatment was guided by PGx versus TAU while examining response and remission rates. Although data varied, cost effectiveness suggested some positive results with PGx although further investigations are needed due to limitations and lack of studies. Despite many favorable outcomes, more evidence of the effectiveness of PGx is needed to make a concrete recommendation that PGx guided treatment is superior to TAU. Information in this review will help clinicians decide if this is an appropriate option for the treatment of MDD. With continued research and ongoing studies this biotechnology is becoming more available to the mainstream.
Metformin has been proven beneficial for the first-line treatment of type 2 diabetic mellitus (T2DM) due to its efficacy and low adverse effect profile. Current US guidelines do not address the use of early intensive insulin use in T2DM. Treatment plans are slowly adjusted over the months until the A1C goal is met. Insulin is initiated several years after the time of T2DM diagnosis and utilized as second-line therapy. Dual therapy of insulin and metformin have shown regression of T2DM in certain patient populations. However, the linear relationship between diabetes and cardiovascular disease does not show greater improvement with dual aggressive therapy. The ACCORD study found intensive insulin use has led to an increase in mortality in diabetic patients. The purpose of this literature review is to gather data using clinical studies and peer-reviewed articles that can determine if metformin and insulin should be used intensively to lower A1C aggressively compared to using standard therapy of metformin to decrease the long-term effects of abnormal A1C levels.
Hyperactivity is a shared behavior with ASD and Attention Deficit Hyperactivity Disorder (ADHD). Medications such as Methylphenidate (MPH) and α 2-a adrenergic receptor agonists are used to modify hyperactivity behavior in ADHD and thus have been used as management in ASD. A review of literature was done to evaluate the use of medications typically used for ADHD in the use of ASD. The databases searched included PubMED, PsycINFO, Cochrane, and Clinical Key. After reviewing the literature, it was found that both MPH and 2-a adrenergic receptor agonist have a potential role in pharmacotherapy for ASD. MPH may be slightly more effective at reducing hyperactivity-impulsivity behaviors than 2-a adrenergic receptor agonist, however the side effect profile in MPH has led to more discontinuations over 2-a adrenergic receptor agonist. More studies would need to be conducted to validate the findings of this review.
Glucagon-Like Peptide-1s Compared to Sulfonylureas in the Treatment of Adults Diagnosed with Type II Diabetes Mellitus in Primary Care
Type II diabetes mellitus (T2DM) is a prevalent disease in our country. Bullard et al. (2018) report approximately 21 million adults have T2DM in the United States. “The total estimated cost of diagnosed diabetes in 2017 is $327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity” (Yang et al., 2018). Treatment of T2DM is individualized to each patient based on their co-morbidities, fiscal responsibility, and route of administration options. Sulfonylureas and Glucagon-like Peptide-1s (GLP-1) are two classes of antidiabetic drugs that are available for use as second line treatment options after metformin. This review of literature is from articles published in 2008 or later found in the following electronic databases: PubMed, Cochrane Database of Systematic Reviews, DynaMed Plus, ClincalKey, and Scopus. Articles included randomized control trials, systematic reviews, and meta analyses with participants being at least eighteen years old. The review found several benefits of GLP-1s for the treatment of T2DM. The risks of GLP-1s are not found to be as serious as the risks associated with sulfonylureas. Sulfonylureas demonstrate historical data for their use and are available in oral forms as opposed to GLP-1s which is newer but in an injectable form only. Overall, GLP-1s offer greater benefits with minimal side effects that are less severe than sulfonylureas. Limitations to this literature review include lack of articles having direct reviews of GLP-1s and sulfonylureas.
Comparing Rates of Macrosomia and Neonatal Hypoglycemia of Differing Treatment Modalities of Gestational Diabetes Mellitus
Gestational diabetes mellitus (GDM) is a known potential complication that can occur during pregnancy. Unmanaged GDM can result in maternal hyperglycemia, which can cause increased neonatal complications, two of which are macrosomia and neonatal hypoglycemia. To prevent maternal hyperglycemia, treatment of GDM typically begins with dietary changes, home glucose monitoring, increased exercise patterns and other lifestyle modifications. However, if maternal hyperglycemia persists after two weeks of maternal lifestyle modifications, there are not current best practice guidelines established for the treatment of GDM. Historically, subcutaneous multiple daily dosed insulin (MDI) has been the gold standard for treatment after lifestyle modification. However, in more recent years oral antihyperglycemic medications, glyburide and metformin, have seen increased use for the treatment of GDM. Additionally, with advancing technology and the development of continuous subcutaneous insulin infusion (CSII), there is discussion regarding which insulin delivery method will achieve more consistent rates of euglycemia to help reduce rates of neonatal hypoglycemia and macrosomia. This scholarly literature review will provide a general overview of GDM, compare treatment modalities (subcutaneous multiple daily dosages of insulin, continuous subcutaneous insulin infusion, metformin and glyburide) of GDM in terms of rates of neonatal hypoglycemia and macrosomia, and compare the safety of differing treatment modalities.
Chukwuka Oscar Nnoli
Clinical varicoceles are the most frequent physical finding associated with infertile men and impaired semen parameters. There is evidence that suggests varicocele repair improves semen parameter and increases the chances of natural pregnancy. Today, varicocele repair is often combined with assisted reproductive techniques (ART) such as intrauterine insemination (IUI), in Vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). In this literature review, data examining whether varicocelectomy before ART leads to improved pregnancy outcomes is reviewed. Current data suggest that there is a significant clinical benefit when correcting a varicocele in oligospermic men before IVF/ICSI. Similarly, men with non-obstructive azoospermia also benefit from varicocelectomy before IVF/ICSI, but not significantly. Furthermore, in couples seeking to use ART to conceive, varicocelectomy may offer improvement in semen parameters and therefore, decrease the level of ART needed to achieve pregnancy.
Can Early Intervention with Group Therapy or Individual Therapy Improve the Family Dynamic in PTSD Patients?
Post Traumatic Stress Disorder (PTSD) is a mental health disorder that affects an individual directly, while also affecting their family members around them. While PTSD is not directly correlated to the development of Secondary Stress Disorder (STS), PTSD has been shown to lead to increased rates of divorce and mood disorders in children whose parents are diagnosed with PTSD. Children who have grown up with divorced parents, or parents with PTSD, have been shown to have an increased chances of developing mood disorders and risky lifestyle behaviors. The combination of having a parent with PTSD and being divorced would likely increase the odds even further of developing a mood disorder. While there are no set guidelines for the treatment of PTSD, the use of various types of group therapies that include family members has been shown to increase relationship satisfaction. While this type of method is useful, individual therapy or even pharmacological regimens should also be included for best results. Educating family members about PTSD, and what the symptoms look like, can help reduce the increased stress associated with PTSD symptoms. If families are educated properly, divorce rates and mood disorder development among family members can be decreased.
Anxiety affects approximately three to seven percent of the United States population, and nearly 50% of the diagnosed patients fail to respond to first-line treatment regimens (Boland, Duffy, & Meyer 2018). Traditional first-line treatments include medication therapy, cognitive behavioral therapy (CBT), or the combination of both. With such a high initial failure rate, recent studies indicate promising results in managing anxiety with pharmacogenomic testing. Pharmacogenomic testing is allowing providers to prescribe medication based on individual genetic makeup, focusing on how each patient metabolizes certain medications. The purpose of this literature review was to determine if first-line methods or pharmacogenomic testing provide patients with more prompt symptom relief. Through a review of several electronic databases and articles, pharmacogenomic testing is yielding promising results in symptom relief, decreasing healthcare costs, and increasing healthcare efficacy. Not only is pharmacogenomic testing promising for anxiety management, it also gives insight to several other medication classes. With this information, pharmacogenomic testing may soon be a screening tool in future medicine.
The purpose of this research and systematic literature review is to determine the risks factors for, the identification of and repercussions of provider suicide. In this review, databases searched included Pubmed, Cochran Database of Systematic Reviews, PsycInfo, National Institute of Health, Medscape and Google Scholar from September 8, 2018 to January 13, 2019. A variety of key terms were used when searching include suicide, provider suicide, suicide, costs of suicide, physician burnout, physician assistant burnout, nurse burnout, doctor suicide, physician assistant suicide, and nurse practitioner suicide. Works chosen for review were published between 1979 and 2018, as the topic has an extended history. Peer reviewed articles including systematic reviews and meta-analysis are included. Editorials were also included for the psychological factors of the topic. The research presented shows evidence that suicide is increased in healthcare providers, especially in women. This is an extremely important topic when considering the number of women entering healthcare. More research still needs to be done to address how suicide also affects all types of providers including nurse practitioners and physician assistants.
• Evidence shows that bacterial vaginosis (BV) can lead to poor perinatal outcomes.
• The goal of this project is to answer the question of which pregnant patients should be screened for BV and does identification and treatment of BV during pregnancy improve perinatal outcomes.
• Due to variability in a multitude of factors, a generalized recommendation is difficult to make. Lack of recommendations are largely due to harm of treatment in those who were misdiagnosed.
• The development of polymerase chain reaction (PCR) has the capability to reduce misdiagnosis.
• Newer studies have shown benefit of early screening and treatment and the use of clindamycin over the traditional treatment of metronidazole.
• An online search of PubMed, CINHAL, and Cochrane databases in the past 10 years yielded meta-analyses, systematic reviews, random control trials, and cohort studies. Additional sources found using reference lists. Search terms utilized included; bacterial vaginosis, vaginitis, pregnancy, pregnant, miscarriage, screening, pre-term, and asymptomatic.
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