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European Consortium for Emergency contraception launched at ESC in Athens

3 Aug, 12 | by shellraine, e-Media Editor

The European Consortium for Emergency contraception (ECEC) was launched in Athens on June 21st at the 12th Congress of the European Society for Contraception and Reproductive Health.

Why a European Consortium on EC, now?

  • Access to emergency contraception (EC) is unequal across the region.
  • Absence of a harmonised evidence-based approach to EC recommendations.
  • Current changes in the EC landscape are likely to lead to further inequalities in access to reliable EC options.
  • The International Consortium for Emergency Contraception (ICEC) works to expand access to EC worldwide, but focuses on the developing world.
  • ICEC and partners identified a need to develop a regional platform to serve as an authoritative source of information, and a voice for more equitable access to EC in Europe.

ECEC mission:

To expand knowledge about and access to EC in European countries, and to promote the standardisation of EC services delivery in the European context, to ensure equitable access within the region. (not only with the 27 EU countries, but with all countries considered Europe by the EU and the WHO.)

ECEC objectives:

KNOWLEDGE – Generate knowledge and serve as an information-sharing platform.
RESEARCH – Promote high quality research on EC issues.
ADVOCACY – Disseminate research findings and promote use of evidence-based information for policy and program development.
QUALITY OF CARE – Reduce access inequalities by promoting the standardization of quality of care of EC services across the region.
IEC – Develop and disseminate information, education and training materials.

How to become a member?

Individual membership – Email info@ec-ec.org and join or via http://knowledge-gateway.org/ICEC/Global/ecec

Institutional membership (terms under development).

Other ESC News

The Congress in Athens was well attended (1400 delegates) despite the reduction in drug company support, most notably for UK clinicians.

At the General Assembly the venue for the 2016 Congress was voted for and won by Basle in Switzerland, which is also the base of the current president – Johannes Bitzer.

  •  In case you hadn’t heard there is an extra Congress next year – the first Global Congress – in Copenhagen. An outline programme, information and calls for papers are available from the website: www.escrh.eu. The abstract submission deadline is 15 December 2012. Why not send something in? You may win an award: best poster, best free communication and for the under 35s, best Young Scientist.
  • The next biennial Congress is in 2014 and will be in Lisbon.

At the Board meeting Professor Kristina Gemzell-Danielsson, from the Karolinska Institute in Sweden, was elected Vice President.

 

 

 

SRH Reports from around the globe

25 May, 12 | by shellraine, e-Media Editor

International Campaign for Women’s Right to Safe Abortion

The ICMA have launched a new international campaign for women’s right to safe abortion. Individuals and organisations are invited to join the campaign in advance of 28 May, the International Day of Action for Women’s Health. To read more and to register support go to https://www.surveymonkey.com/s/CHH62F5

UNFPA announces ‘Maternal Deaths Halved in 20 Years’.

The number of women dying of pregnancy and childbirth related complications has almost halved in 20 years, according to new estimates released by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA) and the World Bank.

US regulators vote for approval of PrEP by large majority.

The US Food and Drug Administration (FDA) have taken a decisive step towards approving the use of the combination pill Truvada (tenofovir/FTC) as a prevention method for HIV-negative people. Read more at NAMaidsmap. GlobalData.com reported on 11th May – In a controversial decision on May 10, the FDA antiviral drugs advisory committee backed Gilead Sciences’ drug Truvada to prevent the transmission of HIV. The committee voted in favour of prophylactic Truvada in three populations: HIV-uninfected men who have sex with men (19-3), in HIV-uninfected partners in relationships with infected partners (19-2), and for individuals at risk of acquiring HIV through sexual activity (12-8).  Although awareness of HIV and AIDs has significantly increased throughout recent decades, the disease remains a global epidemic requiring better preventative strategies. Yet the possibility that on June 15 the FDA will approve Truvada for pre-exposure prophylaxis (PrEP) has provoked strong and divided opinions from infectious disease experts and activists. Read more at globaldata.com

Victories for Center for Reproductive Rights

Victory for Honduran Women

On May 17, 2012, the Center for Reproductive Rights held a demonstration on the steps of the Honduran Congress. Their mission: to stop the government from passing a bill that would have imprisoned women for using emergency contraception. Alejandra Cárdenas, Legal Adviser for Latin America and the Caribbean, had planned to personally hand-deliver 730,000 petitions to the Congress signed by activists in more than 80 countries in protest. In a surprise move, Juan Orlando Hernández, president of the Congress, declined to take the petitions—but not because he didn’t hear the massive outcry. In fact, Hernández said he no longer planned to bring the bill up for debate—and even proclaimed support for women’s self-determination. Read more:

Two Groundbreaking Victories in Oklahoma:

Medication Abortion Protected

Judge Donald Worthington permanently blocked a state ban on medical abortion when he ruled that the law was “so completely at odds” with standard medical practice that it “can serve no purpose other than to prevent women from obtaining abortions and to punish and discriminate against those women who do. Read more:

and Oklahoma Personhood defeated

With a unanimous decision by the Oklahoma Supreme Court, the Center for Reproductive Rights has won its legal challenge to strike down a ballot initiative that would have given every fertilized egg the full legal rights of a person. It is not acceptable, they ruled, to propose amendments to the state constitution that are ‘repugnant to the Constitution of the United States.’” If passed, the amendment not only would have outlawed abortion in all cases—including in cases of rape or incest, fetal anomalies, or risk to a woman’s life—but also would have banned many forms of birth control and seriously threatened fertility treatments such as IVF. Read more:

Distress of child war and sex abuse victims halved by new trauma intervention

A new psychological intervention has been shown to more than halve the trauma experienced by child victims of war, rape and sexual abuse. Researchers at Queen’s University Belfast pioneered the intervention in conjunction with the international NGO, World Vision as part of a wider programme to treat psychological distress in child victims of war and sexual violence in the Democratic Republic of Congo (DRC). Read more:

Melinda Gates’ New Crusade & Confirmation that IUD is most effective for EC

11 May, 12 | by shellraine, e-Media Editor

Melinda Gates’ New Crusade: Investing Billions in Women’s Health

Melinda Gates this week pledged billions of dollars to be spent on improving access to contraception. In her many travels she repeatedly met women who were unable to gain access to something which most of the rest of the world take for granted. In an interview with Newsweek she recounted stories from the women many of whom were unable, for example, to get repeat injections of Depo Provera. In July she is teaming up with the British government to cosponsor a summit of world leaders in London, to start raising the $4 billion the Foundation says it will cost to get 120 million more women access to contraceptives by 2020. And in a move that could be hugely significant for American women, the Foundation is pouring money into the long-neglected field of contraceptive research, seeking entirely new methods of birth control. Ultimately Gates hopes to galvanize a global movement. “When I started to realize that that needed to get done in family planning, I finally said, OK, I’m the person that’s going to do that,” she says. More from the Gates Foundation website.

Paper confirms EC IUD failure rate less than 1 per 1000

Authors of the first ever systematic review of all available data from the last 35 years argue that IUDs should be routinely offered and available to those requesting emergency contraception. They found that the failure rate was less than 1 per 1000 when they analysed data from 42 studies involving 7034 women using 8 different IUDs. They also found that 85% clinicians in one study never offered this as an option. In a press release this week one of the authors, Professor James Trussell, said:

“This is an extremely difficult problem to deal with, especially as in many countries women can just go to their local pharmacy to obtain the ‘morning after pill’, but virtually no women know to ask for an IUD and many family planning clinics and surgeries do not offer same-day insertion. Offering same-day insertion would remove a huge barrier to the greater use of IUDs.”

Online First – Postnatal contraceptive choices in HIV-positive women [Duncan et al.]

Gillian Robinson (Associate Editor) writes:

“This paper describes an exciting example of how an integrated contraception and sexual health service can work to provide holistic care for women. This clinic provides women living with HIV with prenatal, antenatal and postnatal care in a community setting. The paper is a retrospective case note review. Uptake of postnatal contraception was high yet more than 20% of women were not seen postnatally. The authors suggest that the reasons for this are explored to ensure all women with HIV receive contraception in the early postnatal period to prevent unwanted pregnancy.”

NAT calls for new health bodies to tackle late diagnosis of HIV

“Halve It”, a broad coalition of leading experts and advocates in HIV and AIDS, welcomes the renewed call by the National AIDs Trust (NAT) for the urgent prioritisation of HIV testing in its new ‘HIV testing action plan’ which provides vital strategic guidance to health bodies on tackling the serious issue of late HIV diagnosis in the UK.

FDA Approves first pill for Heavy Menstrual Bleeding (HMB)

Natazia is a combination oral contraceptive (COC) consisting of estradiol valerate and estradiol valerate/dienogest. The US Food and Drug Administration (FDA) first approved Natazia in May 2010 to prevent pregnancy. On March 14, 2012, the FDA also approved Natazia to treat heavy menstrual bleeding (HMB), making it the first and only OC indicated for this purpose. One interesting thing is that until now we have known Natazia, in the UK, as Qlaira and until now it has not been widely used. More details at Medscape.

UK women misdiagnosing genital infections

To mark National BV Day on 18th April a study found that one in four British women has misdiagnosed themselves on the internet. Researchers found Dr Google is now the first port of call for women with genuine health concerns who are almost twice as likely to check online before consulting a doctor or even talking to Mum. But searching their symptoms online and self-medicating has led a tenth of the country’s women to endure unpleasant side effects as a result of their misdiagnosis.

 

News items from April

4 May, 12 | by shellraine, e-Media Editor

Better access to birth control would reduce stress on global resources

as reported by Nigel Hawkes in the BMJ. The rich should consume less and the poor should procreate less, says the Royal Society in a new report. The report was produced by a working party chaired by John Sulston, who headed the UK part of the Human Genome Project, and took 21 months to research and write.

Morning after pill courier service launched

A new service allows women (living in London) to order emergency contraception on the internet, so it arrives within two hours, rather than having to see their GP to obtain the drugs. For £20, women can order the drug by filling out an online form through the internet medical practice DrEd.com. The forms, which ask users to confirm they are aged over 18, will be assessed by doctors before pills are dispatched by courier. Currently they only offer Levonelle®, which can also be purchased in advance and by buying 2 packets for £24.00 at a saving of 37%.

Pharmacists should provide oral contraceptive services, says NHS report

As reported by Jacqui Wise in the BMJ:
“A report from NHS South East London has recommended that trained community pharmacists provide oral contraceptive consultation services after a successful pilot scheme to widen access to contraception.  The part of the report that has received the most media coverage is a recommendation to “consider providing the service to women under 16 years where appropriate.” The report said that this may help reduce numbers of teenage pregnancies.”

Brook and fpa respond to proposal to introduce contraceptive pill in pharmacies

Responding to the proposal that the contraceptive pill should be available from pharmacies without a prescription to young people, including those under 16, the chief executives of Brook and FPA, Simon Blake and Julie Bentley said: “The majority of young people under 16 are not having sex, however we must ensure that those who are can access support and services when they need to. “Although Brook and FPA welcome proposals which could increase young people’s access to sexual health services and information, all the necessary safeguards must be in place to ensure young people can get the information and support they need. “This includes pharmacists having the appropriate clinical knowledge about contraception, being able to communicate effectively with young people, having the right type of environment including a confidential space, as well as the appropriate support and referral networks.”

Egg-Sharing in Fertility Treatment

Evaluating egg-sharing: new findings on old debates – as reported in BioNews
Egg-sharing refers to a scheme where a woman undergoing fertility treatment donates a portion of her eggs to an anonymously matched recipient in exchange for a reduction in treatment costs. As a very specific form of egg donation, egg-sharing has generated heated debate since its introduction in the UK in 1998. While proponents argue it provides a win-win solution, allowing two women to help each other conceive, critics talk of the potential ethical and psychological consequences. Until recently, there has been very little empirical data to inform these discussions. However, new research conducted by Gurtin and Golombok at the University of Cambridge Centre for Family Research, in collaboration with the London Women’s Clinic, hopes to redress this balance.

Men’s health expert presents to Members of European Parliament

A leading men’s health expert presented a report detailing the health challenges facing men across Europe MEPs and key European decision-makers at the European Parliament in Brussels.

Professor Alan White, Director of the Centre for Men’s Health at Leeds Metropolitan University was commissioned by the European Commission to produce a report which gives the first complete picture of the breadth of issues affecting men’s health across Europe.  Professor White brought together 36 leading researchers from 34 countries across Europe to undertake the research which highlights the state of men’s health in Europe as a serious public health concern. more info

Faculty Consultations

The CEU Guideline on “Barrier Methods-Contraception and STI prevention” is for consultation until 21st May. see FSRH website:

BASHH Mentoring Group is currently seeking new members:

BASHH would like new representatives to support coordination of mentors and mentees within North West regions and Wales. The successful candidates would also be involved in the activities that the Mentoring Group is currently taking forward nationally. Closing date for applications: 16th May 2012.  see BASHH website for more details

And finally – we hear reports that Virgin Care have obtained ‘preferred bidder’ status in the tender to run West Sussex sexual health services .

Faculty News

10 Feb, 12 | by shellraine, e-Media Editor

Amendments to FSRH Guidance Documents: Drug Interactions and Emergency Contraception
Drug Interactions (2011): Page 9 of the original version of this CEU Guidance Document (issued in January 2011) incorrectly stated that the interaction between lamotrigine and combined hormonal contraception (CHC) only applies to lamotrigine monotherapy. CHC also reduces lamotrigine levels when lamotrigine is combined with antiepileptic drugs that
do not alter its metabolism.

Emergency Contraception (2011): The original version of this CEU Guidance Document (issued in August 2011) contained some inconsistencies that the CEU has corrected in this version. These amendments are as follows: additional recommendation regarding offering a Cu-IUD to eligible women presenting between 0 and 120 hours of UPSI or within 5 days of expected ovulation added (pages ii and 8); references 12 and 13 updated (page 11); and acknowledgement of chart designer added to Appendix 2 (page 15).

New Examiners for the Multiple Choice Question Paper (MCQ)
The Examination Committee invites applications to join the MCQ Examiner Group of the MFSRH Panel of Examiners. Applicants should be accredited Members of the Faculty and active clinically in the sphere of the Faculty or, to be Clinicians, of equivalent status, with an interest in Sexual and Reproductive Healthcare but whose speciality is GUM, Public Health Medicine, Gynaecology or Primary Care. Further information and application forms from the Faculty website, closing date 29th February.

Committee Vacancies

  • Clinical Standards: for a doctor and a nurse
  • Workforce Planning: for an Associate member and a Fellow/Member/Diplomate

Information and details of how to apply are available from the committee’s page of the Faculty website

and in other news

Oral Ulipristal Proves Highly Effective for Uterine Fibroids
According to 2 studies published this week in the New England Journal of Medicine the oral selective progesterone receptor modulator, ulipristal, proved highly effective as a treatment for symptomatic uterine fibroids rapidly reducing excessive bleeding and reducing the size of uterine fibroids, and was well tolerated. The drug was approved for emergency contraception in 2010. Known as ella (HRA Pharma) in the United States and ellaOne in Europe, ulipristal works by interrupting ovulation. For emergency contraception, a 30-mg dose is used. By contrast, the newly-published studies tested 5-mg and 10-mg daily doses for fibroid treatment. In one of the studies (placebo-controlled) the drug controlled excess menstrual bleeding in over 90% of cases with a high incidence of amenorrhoea. If and when a product becomes available in the UK (Esmya is already approved and licensed in other countries) the issue of contraception will need to be highlighted to those that might use it because of the interaction with hormonal contraception.

Review of the year 2011

6 Jan, 12 | by shellraine, e-Media Editor

It has been a busy and eventful year in sexual and reproductive health:

January

saw the launch of the new-look Journal of Family Planning & Reproductive Health Care as it joined the BMJ family. Readers will have noticed many improvements, not least the website and early online publishing.

February

The joint Faculty / e-Learning for Health, e-SRH, was named winner in the e-Government National Award: excellence, Learning & Skills section (now renamed UK Public Sector Digital Awards)

March saw the MDU statement: GPs need suitable training to fit contraceptive implants

April saw the Faculty response to EC being made available through pharmacies in Wales

May saw the publication of the new Missed Pill Recommendations

June

saw Chris Wilkinson become the newly elected President of the Faculty and in
July his appoinment was acknowledged in BMA News


August

saw the publication of the Emergency Contraception Guidelines



September
saw the publication of the amended Drug Interactions with Hormonal Contraception and the launch of this Blog !!

October saw the publication of the Combined Hormonal Contraception Guidelines as the world population broke the 7 billion mark.

November
saw the CEU being awarded NHS Accreditation for its guidelines and the publication of the Service Standards for SRH

December
saw the 23rd World AIDS Day with the theme: Getting to Zero

And so to 2012 – wishing all our readers a Happy New Year

Online First and Emergency Contraception for Christmas

16 Dec, 11 | by shellraine, e-Media Editor

The latest article to be published at Online First is:

Questions about intimate partner violence should be part of contraceptive counselling: findings from a community-based longitudinal study in Nicaragua by Mariano Salazar, Eliette Valladares, Ulf Högberg.

Neelima Deshapande (Associate editor) writes:

Effect of domestic violence on contraceptive choice

Sadly, domestic violence against women continues in many countries. This study from Nicaragua looks at the impact of intimate partner violence (IPV) on the choices that women make about their contraception. It appears that women who are abused tend to use more reversible contraception than women who are not and that women actually make conscious choices about delaying pregnancies far more often when their partner is violent than if they are in a non-violent relationship This study quantifies the high proportion of women suffering from IPV and adds strength to the argument that enquiry about domestic violence should be included in contraceptive choices consultations and steps taken to identify and refer appropriately.

Emergency Contraception in Advance:
The BPAS christmas campaign (at www.santacomes.org) to offer free EHC through the post caused the usual mixed tranche of reactions in the media – all of which will hopefully succeed in raising awareness, as described in Marge Berer’s wonderful blog on 12th December. The FSRH have issued a Faculty statement on the subject saying that at a time of limited access advance provision will be in the best interests of many women.

FPA/Brook have issued a response to the Systematic Review of Induced Abortion and Women’s Mental Health discussed last week.

FPA have, today, issued a reaction to the Health Survey for England 2010, published yesterday, which shows that 1 in 4 women claim to have lost their virginity before their 16th birthday. Like the BPAS EHC campaign, above, the Survey has brought out the worst of our tabloid and conservative press with predictable, extreme headlines. However, as reported in The Independent, the authors noted that surveys of sexual behaviour are hard to interpret as responses are subject to both exaggeration and concealment. In addition (but less reported) it showed 26% of women and 32% of men aged 16 to 24 say they have never had sex and across all age groups, men have typically had 9.3 female sexual partners in their lifetime, while women have slept with an average of 4.7 men and almost a quarter of all women (24%) have only ever had one sexual partner, compared to 17% of men. With regards to methods of contraception it showed that equal numbers of women (22%) were using condoms or pills compared with 7% using LARC.

Faculty Gains NHS Accreditation for Guidelines

11 Nov, 11 | by shellraine, e-Media Editor

The Clinical Effectiveness Unit (CEU) of the Faculty of Sexual & Reproductive Healthcare (FSRH) has achieved NHS Accreditation for the process used to produce its guidelines. The NHS Evidence Accreditation Scheme recognises organisations that demonstrate high standards in producing health or social care guidance. It is stated that users of accredited guidance can therefore have high confidence in the quality of the information. In future all CEU guidance will display the Accreditation Mark.

This coincides with the release of the latest clinical guidance: Combined Hormonal Contraception – an updated and extended version of the previous guidance on combined oral contraception published in 2006. There are now clinical guidelines on the vast majority of currently available methods as well as Drug Interactions, Quick Starting (methods), Emergency Contraception and others for specific, special groups. This is in addition to the UK Medical Eligibility Criteria.

The CEU was launched in 2002 and after initially being based in Aberdeen transferred to Sandyford in Glasgow in 2008. The director of the current unit is Dr Louise Melvin and its main tasks are producing evidence based guidance, new product reviews and running the Members Enquiry Service.

Clinical guidelines that are evidence-based are an important element of current clinical practice and underpin clinical competence and governance. Along with training they have the potential to raise standards and improve quality of care, though as their name suggests they are intended to guide clinical care not replace clinical judgement as they are applied to general situations rather than to individuals.  In sexual and reproductive health care CEU guidance and FSRH training is increasingly seen as the gold standard by which clinical care is likely to be judged. An example of this was seen earlier this year in a statement from the MDU in response to an increase in the number of claims related to problems with subdermal implants by GPs. The statement stresses the need for, particularly, GP members to ensure they have appropriate training and should ideally hold a Letter of Competence from the Faculty.

From the Journal – October 2011 issue

6 Oct, 11 | by shellraine, e-Media Editor

The newly published Journal includes a number of articles related to abortion: a book review; a commentary on medical abortion in Ethiopia – for which there is also a podcast; an Israeli view of the status of a foetus; HIV testing in clinics and repeat attendance in Britain.

In addition there is a profile of FIAPAC, the international organisation for abortion providers who have their next biennial Congress in Edinburgh in October 2012.

In Letters to the Editor there is continuing correspondence discussing the emotive subject of the use of cervical analgesia for IUD/IUS fitting which seems to have polarised opinion more than any other issue for some time.

The printed journal was accompanied by the most recently published Faculty Guidance on Emergency Contraception (2011), available electronically from: http://www.fsrh.org/pdfs/CEUguidanceEmergencyContraception11.pdf. This updates the previous guidance from 2006, includes the new oral preparation, ulipristal acetate, a progesterone receptor modulator licensed for use up to 5 days after unprotected sex and refers to the guidance for Quick Starting Contraception (2010) which details how to ‘quick start’ after use of emergency contraception.

This Guidance follows neatly on from the CEU Statement on Missed Pill Recommendations (May 2011), which accompanied the last edition of the Journal which also included a commentary by Dr Diana Mansour; Revision of the ‘missed pill’ rules, which details the background to the changes.  The statement was published after the MHRA asked the Faculty Clinical Effectiveness Unit to review its previous guidance (2005), with a view to producing harmonised guidance. This the CEU subsequently did and the new guidance has been endorsed and adopted by the MHRA, fpa and BNF although unfortunately not by the pharmaceutical industry.

BNF 62 includes the amended instructions for starting and switching combined hormonal contraception to take into account the above recommendations.  Continuing the initiative of working closely with the Clinical Effectiveness Committee the BNF section on Contraception (7.3) is up to date and in line with FSRH guidance. This makes it an accurate resource particularly for GPs and Practice Nurses who use it more than any other group of clinicians.

CD ROMs

The latest Faculty Presidents Newsletter, which also accompanied the print journal, highlights the need for all services and clinicians to dispose of and not use any of the old training CD ROMs for IUDs, implants and EC. Trainees should only use the up-to-date training modules from the e-learning website: www.e-lfh.org.uk.

Welcome to the Journal of Family Planning blog

28 Sep, 11 | by shellraine, e-Media Editor

My aim is to bring you news, views and information in the field of contraception and sexual health – some of which you may have seen and some not. I hope that as well as highlighting articles and issues from our journal this will signpost current issues and initiatives from the UK and around the world.

It has been an eventful year in contraception with a number of changes for clinical practice and over the coming weeks I will revisit the most important of these.

A round-up of some recent news items includes:

Mary Robinson calls for more funds for Family Planning.

As world leaders collected at the UN in New York last week Mary Robinson, the first woman president of Ireland (1990-1997), UN High Commissioner for Human Rights from 1997-2002, and chairwoman of the Global Leaders Council for Reproductive Health called for them to make good on their promise of 17 years ago at the UN International Conference on Population and Development in Cairo, when they agreed to make contraceptive services available for women all over the world by 2015. http://www.newsday.com/opinion/oped/robinson-more-funds-for-family-planning-1.3187083

WHO Medical Eligibility Criteria for Contraceptive Use 4th ed wins first prize in the BMA Book Awards (O&G category).

The WHO MEC are the basis from which the UK MEC were developed and underpin clinical practice in contraception and sexual health. The most recent version of the UKMEC was published 2009:http://www.fsrh.org/pdfs/UKMEC2009.pdf

Medscape Education Clinical Briefs report a pooled analysis of 2 studies which seem to demonstrate that Intrauterine Devices Lower Cervical Cancer Risk. This involved 10 case-control studies done in 8 countries, and 16 studies of HPV prevalence from 16 countries looking at risks for cancer of the cervix and HPV in IUD users. http://www.medscape.org/viewarticle/749724?src=cmemp

In Rwanda, Africa’s most densely populated country, men are being encouraged to have vasectomies. The no-scalpel procedure is being offered for free according to a report in the Independent Newspaper on 7th September.

Unapproved emergency birth control medicine in U.S. may be ineffective and unsafe. In July the FDA issued a warning to consumers not to buy a product named Evital as they may have been counterfeit. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm265847.htm

I welcome comments from readers and will publish those that I feel will be helpful to others.

Latest from JFPRHC

Latest from JFPRHC