Digital Commons Network^™

Participant- And Disease-Related Factors As Independent Predictors Of Treatment Outcomes In The Restore-Imi 2 Clinical Trial: A Multivariable Regression Analysis, Ignacio Martin-Loeches, Andrew F Shorr, Marin H Kollef, Jiejun Du, Maria C Losada, Amanda Paschke, C Andrew Deryke, Michael Wong, Erin H Jensen, Luke F Chen

2020-Current year OA Pubs

BACKGROUND: In the RESTORE-IMI 2 trial, imipenem/cilastatin/relebactam (IMI/REL) was noninferior to piperacillin/tazobactam in treating hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia. This post hoc analysis was conducted to determine independent predictors of efficacy outcomes in the RESTORE-IMI 2 trial, to assist in treatment decision making.

METHODS: A stepwise multivariable regression analysis was conducted to identify variables that were independently associated with day 28 all-cause mortality (ACM), favorable clinical response at early follow-up (EFU), and favorable microbiologic response at end of treatment (EOT). The analysis accounted for the number of baseline infecting pathogens and in vitro susceptibility to randomized treatment.

RESULTS: Vasopressor use, …

Acinetobacter Baumannii Atcc 17978 Encodes A Microcin System With Antimicrobial Properties For Contact-Independent Competition, Fabiana Bisaro, Howard A Shuman, Mario F Feldman, Michael J Gebhardt, Stefan Pukatzki

2020-Current year OA Pubs

No abstract provided.

Interstitial Nephritis: Wherefrom, Wherein, And Whereto, Garabed Eknoyan

Faculty, Staff and Students Publications

Abnormalities of the renal interstitium were noted early while identifying chronic kidney disease in 1827; however, interest in glomerular and vascular lesions was then distracted from their further study. As a complication of scarlet fever, interstitial lesions attracted attention in 1859 and came to be defined as acute interstitial nephritis in 1898. The chronic form of interstitial nephritis was traditionally attributed to pyelonephritis until the advent of kidney biopsy in the 1950s, when interstitial lesions were recognized as an independent primary cause of chronic kidney disease from studies of analgesic nephropathy and vesico-ureteral reflux. The term tubulointerstitial nephritis was introduced …

Vaccine Access, Equity And Justice: Covid-19 Vaccines And Vaccination, Lois Privor-Dumm, Jean-Louis Excler, Sarah Gilbert, Salim S Abdool Karim, Peter J Hotez, Didi Thompson, Jerome H Kim

Faculty, Staff and Students Publications

Although significant progress has been made in achieving goals for COVID-19 vaccine access, the quest for equity and justice remains an unfinished agenda. Vaccine nationalism has prompted calls for new approaches to achieve equitable access and justice not only for vaccines but also for vaccination. This includes ensuring country and community participation in global discussions and that local needs to strengthen health systems, address issues related to social determinants of health, build trust and leverage acceptance to vaccines, are addressed. Regional vaccine technology and manufacturing hubs are promising approaches to address access challenges and must be integrated with efforts to …

Evaluating Demographic Representation In Clinical Trials: Use Of The Adaptive Coronavirus Disease 2019 Treatment Trial (Actt) As A Test Case, Ana M Ortega-Villa, Noreen A Hynes, Corri B Levine, Katherine Yang, Zanthia Wiley, Nikolaus Jilg, Jing Wang, Jennifer A Whitaker, Christopher J Colombo, Seema U Nayak, Hannah Jang Kim, Nicole M Iovine, Dilek Ince, Stuart H Cohen, Adam J Langer, Jonathan M Wortham, Robert L Atmar, Hana M El Sahly, Mamta K Jain, Aneesh K Mehta, Cameron R Wolfe, Carlos A Gomez, Tatiana Beresnev, Richard A Mularski, Catharine I Paules, Andre C Kalil, Angela R Branche, Annie Luetkemeyer, Barry S Zingman, Jocelyn Voell, Michael Whitaker, Michelle S Harkins, Richard T Davey, Robert Grossberg, Sarah L George, Victor Tapson, William R Short, Varduhi Ghazaryan, Constance A Benson, Lori E Dodd, Daniel A Sweeney, Kay M Tomashek

Faculty, Staff and Students Publications

Background: Clinical trials initiated during emerging infectious disease outbreaks must quickly enroll participants to identify treatments to reduce morbidity and mortality. This may be at odds with enrolling a representative study population, especially when the population affected is undefined.

Methods: We evaluated the utility of the Centers for Disease Control and Prevention's COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), the COVID-19 Case Surveillance System (CCSS), and 2020 United States (US) Census data to determine demographic representation in the 4 stages of the Adaptive COVID-19 Treatment Trial (ACTT). We compared the cumulative proportion of participants by sex, race, ethnicity, and age enrolled at …

Covid-19 Vaccines And The Pandemic: Lessons Learnt For Other Neglected Diseases And Future Threats, Peter J Hotez, Sarah Gilbert, Melanie Saville, Lois Privor-Dumm, Salim Abdool-Karim, Didi Thompson, Jean-Louis Excler, Jerome H Kim

Faculty, Staff and Students Publications

Through the experiences gained by accelerating new vaccines for both Ebola virus infection and COVID-19 in a public health emergency, vaccine development has benefited from a 'multiple shots on goal' approach to new vaccine targets. This approach embraces simultaneous development of candidates with differing technologies, including, when feasible, vesicular stomatitis virus or adenovirus vectors, messenger RNA (mRNA), whole inactivated virus, nanoparticle and recombinant protein technologies, which led to multiple effective COVID-19 vaccines. The challenge of COVID-19 vaccine inequity, as COVID-19 spread globally, created a situation where cutting-edge mRNA technologies were preferentially supplied by multinational pharmaceutical companies to high-income countries while …

Association Of Area Deprivation Index With Severity Of Covid-19 In Pediatric Patients: A Multisite Study Of Racially And Ethnically Diverse Children, Sebastian Acosta, Srinivasan Suresh, Anna K Ettinger, Fabio Savorgnan, Ananth Annapragada, Nirupama Kannikeswaran, Usha Sethuraman

Faculty, Staff and Students Publications

Area deprivation index (ADI) is associated with the risk of severe COVID-19 in adults. However, this association has not been established in children. Information on ADI, demographics, clinical features, disease severity, and outcomes was analyzed for 3434 children with COVID-19. A multivariate logistic regression revealed that non-Hispanic Asians, extremes of weight, and higher ADI were associated with severe disease.

Interleukin-18 Signaling Promotes Activation Of Hepatic Stellate Cells In Mouse Liver Fibrosis, Jana Knorr, Joel D. Schilling, Et Al.

2020-Current year OA Pubs

BACKGROUND AND AIMS: Nucleotide-binding oligomerization domain-like receptor-family pyrin domain-containing 3 (NLRP3) inflammasome activation has been shown to result in liver fibrosis. Mechanisms and downstream signaling remain incompletely understood. Here, we studied the role of IL-18 in hepatic stellate cells (HSCs), and its impact on liver fibrosis.

APPROACH AND RESULTS: We observed significantly increased serum levels of IL-18 (128.4 pg/ml vs. 74.9 pg/ml) and IL-18 binding protein (BP; 46.50 ng/ml vs. 15.35 ng/ml) in patients with liver cirrhosis compared with healthy controls. Single cell RNA sequencing data showed that an immunoregulatory subset of murine HSCs highly expresses Il18 and Il18r1 . …

Factors, Enablers And Challenges For Covid-19 Vaccine Development, Jean-Louis Excler, Melanie Saville, Lois Privor-Dumm, Sarah Gilbert, Peter J Hotez, Didi Thompson, Salim Abdool-Karim, Jerome H Kim

Faculty, Staff and Students Publications

The COVID-19 pandemic triggered a sense of vulnerability and urgency that led to concerted actions by governments, funders, regulators and industry to overcome traditional challenges for the development of vaccine candidates and to reach authorisation. Unprecedented financial investments, massive demand, accelerated clinical development and regulatory reviews were among the key factors that contributed to accelerating the development and approval of COVID-19 vaccines. The rapid development of COVID-19 vaccines benefited of previous scientific innovations such as mRNA and recombinant vectors and proteins. This has created a new era of vaccinology, with powerful platform technologies and a new model for vaccine development. …

Dementias Among Older Males And Females In The U.S. Medicare System With And Without Hiv, Xiaoying Yu, Yong-Fang Kuo, Mukaila A Raji, Abbey B Berenson, Jacques Baillargeon, Thomas P Giordano

Faculty, Staff and Students Publications

Background: Despite the growing concern that people with HIV (PWH) will experience a disproportionate burden of dementia as they age, very few studies have examined the sex-specific prevalence of dementia, including Alzheimer disease and related dementias (AD/ADRD) among older PWH versus people without HIV (PWOH) using large national samples.

Methods: We constructed successive cross-sectional cohorts including all PWH aged 65+ years from U.S. Medicare enrollees and PWOH in a 5% national sample of Medicare data from 2007 to 2019. All AD/ADRD cases were identified by ICD-9-CM/ICD-10-CM diagnosis codes. Prevalence of AD/ADRD was calculated for each calendar year by sex-age strata. …

A Pandemics Treaty: A Boon For Africa, Kafumu Kalyalya

Southern African Journal of Policy and Development

This article illustrates the weaknesses of the current global health framework. It highlights two pillars a new treaty regime ought to be built upon. The analysis seeks to establish how these pillars could have helped Africa during the pandemic and can indeed help Africa in future pandemics. The analysis suggests the need for a unified global health regime or pandemics’ treaty that promotes a level legal and political playing field regarding future pandemics. The treaty could focus on coordination of research and development; build a stronger global framework that reinforces legal obligations and norms; provide for universal access to medicines, …

First Rabbit Haemorrhagic Disease Outbreak In Nigeria: Implications For The Growing Rabbit Production Industry, Oluwafemi Daodu, Oladapo Oludairo, Olatunde Akanbi, Isaac Olorunshola, Oluwakemi Daodu, Julius Aiyedun, Clement Meseko

Mansoura Veterinary Medical Journal

The first outbreak of rabbit haemorrhagic disease (RHD) in Nigeria was reported in 2020 after over three decades of its existence in several parts of the world. In this study, we traced the timeline of the 2020 outbreaks of RHD in Nigeria, assessed the knowledge and practices of farmers about RHD and other infectious diseases of rabbits.Structured questionnaire was administered using Google Forms shared through the rabbit farmers’ social media groups and other professional livestock platforms. Responses were obtained from 114 rabbitries across 15 States in Nigeria. Our findings revealed that the 2020 RHDV outbreak started in February, though its …

Predicting Hiv Vaccine-Mediated Protection Level To Identify Immune Correlates Using Positive Unlabeled Learning, Shiwei Xu

Dartmouth College Ph.D Dissertations

The development of a vaccine for Human Immunodeficiency Virus type 1 (HIV-1) is a crucial step in preventing the global spread of AIDS. To ensure the progress and effectiveness of this vaccine, it is essential to establish efficient biotechnology platforms and data mining methods. These methods would help identify immune characteristics that distinguish individuals with varying levels of vaccine-induced protection and determine the underlying factors that contribute to protection against HIV acquisition. While previous studies have focused on identifying immune markers associated with infection outcomes among vaccinated patients, it is important to acknowledge the limitations of traditional case-control analytical protocols …

Development Of Wiskott-Aldrich Syndrome Knock Out Protocol For Drug Substance Assay Development, Julia C. Hanna

Master's Theses

Wiskott-Aldrich Syndrome (WAS) is a rare X-linked primary immunodeficiency affecting approximately 1 in 100,000 live XY births in North America and is caused by a mutation to the WAS gene which is expressed across hematopoietic lineages. The WAS protein (WASp) plays a role in regulating actin polymerization. On a cellular level, there are a variety of effects of a lack of WASp or expression of a dysfunctional WASp protein for patients including issues with migration, adhesion, chemotactic response, phagocytosis, activation, and proliferation across different cell types in addition to reduced platelet size and output. This can lead to several systematic …

Researching Covid To Enhance Recovery (Recover) Adult Study Protocol: Rationale, Objectives, And Design, Leora I. Horwitz, Tanayott Thaweethai, Shari B. Brosnahan, Mine S. Cicek, Megan L. Fitzgerald, Jason D. Goldman, Rachel Hess, S. L. Hodder, Vanessa L. Jacoby, Michael R. Jordan, Jerry A. Krishnan, Adeyinka O. Laiyemo, Torri D. Metz, Lauren Nichols, Rachel E. Patzer, Anisha Sekar, Nora G. Singer, Lauren E. Stiles, Barbara S. Taylor, Shifa Ahmed, Heather A. Algren, Khamal Anglin, Lisa Aponte-Soto, Hassan Ashktorab, Ingrid V. Bassett, Brahmchetna Bedi, Nahid Bhadelia, Christian Bime, Marie Abele C. Bind, Lora J. Black, Andra L. Blomkalns, Hassan Brim, Mario Castro, James Chan

Division of Basic Science Faculty Publications

Importance SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis. …

Mosquito Bed Net Use And Associated Factors Among Pregnant Women In Rwanda: A Nationwide Survey, Joseph Kawuki, Elorm Donkor, Lilian Nuwabaine, Ghislaine Gatasi

School of Nursing & Midwifery, East Africa

Background

In malaria-endemic countries such as Rwanda, the appropriate use of mosquito bed nets is an effective intervention for malaria prevention. Despite being one of the demographics most impacted by malaria, there is a dearth of literature on the usage of mosquito bed nets by pregnant women in Rwanda. The study aimed to assess the prevalence and associated factors for mosquito bed net use among pregnant women in Rwanda

Methods

We used weighted data from the 2020 Rwanda Demographic and Health Survey of 870 pregnant women, and multistage stratified sampling was used to select participants. Multivariable logistic regression was conducted …

The Factors Associated With Caesarean Section At A Rural Hospital In Southwestern Uganda: A Cross-Sectional Study, Lilian Nuwabaine, Mathius Amperiize, Patience Annet Nakalega

School of Nursing & Midwifery, East Africa

Background

Globally, the overall prevalence of caesarean section (CS) is estimated at 18.6%, with 27% in high-income countries and 6% in low- and middle-income countries. There is an increase in trends of CS in Uganda from 8.5% in 2012 to 11% in 2016. No studies have been carried out to account for the high rates of CS at Kisiizi Hospital in Uganda. This study determined the proportion and factors associated with CS delivery at a rural hospital in southwestern Uganda.

Methods

This was a cross-sectional study of 321 immediate postnatal women in a rural hospital in southwestern Uganda. A structured …

Exploring The Experiences Of Pregnant Women In The U.S. During The First Year Of The Covid-19 Pandemic, Courtney E. Williams, Dana Berkowitz, Heather M. Rackin

Faculty Publications

In this paper, we integrate the stress process model with symbolic interactionism to frame our analysis of interviews with 35 women who were pregnant and/or gave birth during the first year of the Covid-19 pandemic. We detail three stressors, highlight their variation, and discuss how they coped with these stressors. Women reported having to navigate contradictory information about the public health crisis, but Black participants simultaneously endured added strain from a heightened awareness of racialized violence. To cope with an overabundance of precarious and contradictory messages, some women sought out information (i.e., information gatherers), others eschewed information (i.e., information avoiders), …

Behavior Changes And Lc50 Of Dried Garlic (Allium Sativum) Acute Toxicity In Nile Tilapia (Oreochromis Niloticus) Juvenile [Research Note], Gregoria Erazo Pagador, Haydee Rose Dumaran Paciente, Blan Jericho Caloyloy

The Philippine Agricultural Scientist

Plant-based compounds are emerging substitutes for chemical treatments in aquaculture since they are known to cause less harm to both the environment and its organisms. Garlic (Allium sativum) is a popular herb that has a broad range of uses, especially in the control and treatment of bacterial and parasitic diseases. However, its toxicity to tilapia is not well-studied. Hence, this study was conducted to test the toxicity levels of garlic powder in juvenile Nile tilapia (Oreochromis niloticus) by determining the cumulative mortality and median lethal concentration (LC₅₀). Test fish were exposed through immersion in …

Effect Of Vitamin C And Probiotics On Broilers Performance And Claudin-2 (Cldn-2) Expression Under Heat Stress [Research Note], Mohammad Chamani, Mohammad Chamani, Farhad Foroudi, Ali Asghar Sadeghi, Mehdi Aminafshar

The Philippine Agricultural Scientist

This study was conducted to investigate the effect of vitamin C and probiotic which consists of five species of beneficial bacteria and two species of fungi on performance, blood parameters, and intestinal CLDN-2 gene expression of broilers during heat stress (HS). A total of 400 broilers were randomly divided into five groups, each of which received a different treatment. The first group was considered a negative control and did not experience any HS (C^-); the second group was considered a positive control (C⁺) and was exposed to HS; the third group received only vitamin C (250 …

Dispersion In Single-Wall Carbon Nanotube Film: An Application Of Bogoliubov–Valatin Transformation For Hamiltonian Diagonalization, Chandra M. Adhikari, Da’Shawn M. Morris, Thomas W. Noonan, Tikaram Neupane, Basu R. Lamichhane, Bhoj R. Gautam

College of Health, Science, and Technology

We present a theoretical study on the energy dispersion of an ultrathin film of periodically-aligned single-walled carbon nanotubes (SWCNTs) with the help of the Bogoliubov–Valatin transformation. The Hamiltonian of the film was derived using the many-particle green function technique in the Matsubara frequency formalism. The periodic array of SWCNTs was embedded in a dielectric with comparatively higher permittivity than the substrate and the superstrate such that the SWCNT film became independent with the axis of quantization but keeps the thickness as the variable parameter, making the film neither two-dimensional nor three-dimensional, but transdimensional. It was revealed that the energy dispersion …

Test-Retest Reliability Of Virtual Reality Devices In Quantifying For Relative Afferent Pupillary Defect, Prithul Sarker, Nasif Zaman, Joshua Ong, Phani Paladugu, Molly Aldred, Ethan Waisberg, Andrew G. Lee, Alireza Tavakkoli

Student Papers, Posters & Projects

Background: The swinging flashlight test (SFT) is one of the most prominent clinical tests for detecting the relative afferent pupillary defect (RAPD). A positive RAPD localizes the lesion to the affected afferent pupil pathway and is a critical part of any ophthalmic exam. Testing for an RAPD, however, can be challenging (especially when small), and there is significant intrarater and interrater variability.

Methods: Prior studies have shown that the pupillometer can improve the detection and measurement of RAPD. In our previous research, we have demonstrated an automatic SFT by utilizing virtual reality (VR), named VR-SFT. We applied our methods to …

Efficacy Of Pure Bioscience Surface Disinfectant On Varying Bacterial Strains, Isabelle R. Mckenzie

Biological Sciences

Agriculture represents a crucial aspect of the acquisition of food resources in modern society. Consequently, it is a paramount undertaking to process crops devoid of any pathogenic agents. A cleaning product named Pure Hard Surface Disinfectant was presented by Pure Biosciences, acclaiming its capacity to destroy bacteria and fungi, while impeding their proliferation for an extended duration following application. This pilot project sought to quantify the efficacy of Hard Surface Disinfectant. Empirical observations conducted thus far have concentrated on surveying the immediate effects of the principal ingredient, silver ion, on diverse bacterial strains. Future prospects for this project include a …

Chronic Hepatitis B, C, And Stroke; Association And Pathophysiology, Hamza Imran, Adnan Yousuf, Mohammad Wasay

Pakistan Journal of Neurological Sciences (PJNS)

Background and Objectives:

Hepatitis infection may raise the incidence of stroke and other cerebrovascular abnormalities, according to several studies. However, its association is controversial. This review looked to compile the most recent research on the relationship between HBV and HCV, atherosclerosis, and stroke.

Methods:This article reviews the literature on the connection between hepatitis B and C viruses with stroke and atherosclerosis. The search included articles from PubMed, PakMediNet, and Google Scholar, as well as a Medline search using specific keywords and MeSH terms. A total of 2655 articles were identified. Out of these 2655 articles we identified 134 articles …

"I Stayed There The Whole Night": Exploring Caregivers' Experiences With The Healthcare System When Caring For A Parent At The End Of Life, Lillian Mehran

Dissertations and Theses

Background: In the United States, there are nearly 53 million individuals serving as caregivers to a loved one. Half of all caregivers are caring for a parent or parent-in-law, and 79% of caregivers are caring for a person aged 50 or older. In New York State, there are an estimated 4.1 million caregivers who collectively provide over 2.6 billion hours of unpaid care, with those caring for a person at the end of life providing twice as many hours of caregiving per week compared to other caregivers. The number of individuals requiring caregiving is expected to increase as a significant …

The Influence Of Microorganisms On Human Health, Tiffany Bui

University Honors Theses

The purpose of this thesis is to explore the interplay between the environment, lifestyle, and composition of human microbiomes across different communities, with a specific focus on immune and digestive health. This literature review investigates three distinct types of communities: isolated/traditional, transitional, and urban/industrialized communities, each characterized by unique environments, societal structures, and interactions. These factors contribute to the distinct microbial populations and compositions within each community. It is impossible to avoid contact with microorganisms as they are present in every aspect of our lives, from the air we breathe, the water we drink, the soil we walk on, the …

A Century-Long Analysis Of Global Warming And Earth Temperature Using A Random Walk With Drift Approach, Leon Wang, Leigh Wang, Yang Li, John Wang

Department of Information Management and Business Analytics Faculty Scholarship and Creative Works

Climate change poses the most significant threat to humanity today. This study examines the global warming trend by analyzing temperature changes over the past century, uncovering alarming results. Various models, including the Random Walk with Drift approach with R programming language, have been used to compare different time horizons and scenarios. This research demonstrates the importance of utilizing advanced analytical techniques to better understand climate change's impact. The findings underscore the urgency of implementing effective climate policies to mitigate the effects of global warming and safeguard our planet's future.

Introduction, Marama Muru-Lanning, Hilary Lapsley

Pacific Studies

This special issue of Pacific Studies focuses on well-being amongst indigenous Pacific elders. Well-being is a widely used concept, but research is lacking on how well-being is understood in Oceania. This issue involves studies on the well-being of elders from Rotuma, Papua New Guinea and Pollap, as well as Māori and Pacific peoples in Aotearoa/New Zealand.

Our collection emphasizes two pou, or posts, supporting well-being amongst Pacific elders. The first, aging in place, has a Pacific twist, where homeplaces are whenua, ancestral places of deep connection imbued with cultural and relational significance. Vā, meaning relational space, is a related concept. …

Vol. 46 No. 1 (2023): Pacific Studies Full Issue, The Jonathan Nāpela Center For Hawaiian And Pacific Islands Studies

Pacific Studies

Pacific Studies is published two times a year by The Jonathan Nāpela Center for Hawaiian and Pacific Studies, Brigham Young University Hawai‘i #1979, 55–220 Kulanui Street, Lā ‘ie, Hawai‘i 96762, but responsibility for opinions expressed in the articles rests with the authors alone. Subscription rate is US$40.00 yearly, payable to The Jonathan Nāpela Center for Hawaiian and Pacific Studies. The Jonathan Nāpela Center for Hawaiian and Pacific Studies (formerly The Pacific Institute) is an organization funded by Brigham Young University Hawai‘i. The Center assists the University in meeting its cultural and educational goals by undertaking a program of teaching, research, …

Does Size Matter? A Randomized Controlled Trial To Assess The Impact Of External Diameter On Adherence To 3 Different Intravaginal Rings Among 24 Us Couples, Irene Bruce, Marlena Gehret Plagianos, Jessica M. Sales, Jessica Atrio, Shakti Shetty, Caio Sant’Anna Marinho, Brady Zieman, Lisa Haddad, Barbara Friedland

Center for Biomedical Research (CBR)

Background: Intravaginal rings (IVRs) are being developed as multipurpose prevention technologies (MPTs) for simultaneous HIV and pregnancy prevention. However, no empirical data exists to support the current 54-58mm size as ideal. Understanding the impact of IVR size on adherence is critical for developing a product that can be used correctly and consistently. Methods: We conducted a randomized, open-label, 3-way crossover trial comparing adherence, preference, and acceptability of 3 non-medicated silicone IVRs of differing external diameters: 46mm, 56mm and 66mm. 24 couples in Atlanta, GA and Bronx, NY were randomized to the sequence of IVR use, used each continuously …