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Mojtahedi SF, Mohammadzadeh A, Mohammadzadeh F, Jalili Shahri J, Bahri N. Association between bacterial vaginosis and 25-Hydroxy vitamin D: a case-control study. BMC Infect Dis 2023; 23:208. [PMID: 37024856 PMCID: PMC10080887 DOI: 10.1186/s12879-023-08120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 02/25/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION Bacterial vaginosis (BV) is the most common vaginal dysbiosis among women of reproductive age. Micronutrient deficiencies, including vitamin D deficiency, can increase the risk of BV. The findings of previous studies regarding the relationship between vitamin D deficiency and BV were conflicting. Therefore, this study aimed to evaluate the association between BV and serum level of 25-hydroxy vitamin D. MATERIALS AND METHODS This case-control study was conducted in Gonabad County in 2021. One hundred and twenty-five confirmed BV cases and 125 controls who were matched based on age and intercourse frequency (maximum difference of two days per week) enrolled in the study. Data collection was performed using a demographic and reproductive data questionnaire and a checklist for recording Whiff test results, serum 25-hydroxy vitamin D level, litmus paper observation, and microscopic findings (clue cells). Serum level of vitamin D was evaluated based on enzyme-linked immunoassay method (Monobind kit) from 0.5 ml venous blood drawn from each participant. The conditional logistic regression model was used to analyze data. RESULTS The BV cases had significantly lower 25-hydroxy vitamin D serum levels than controls. The odds of BV increased with vitamin D deficiency (Adjusted odds ratio (AOR): 4.34, 95% confidence interval (CI): 1.39-13.4, p = 0.011, FDR q-value = 0.051), vitamin D insufficiency (AOR: 3.65, 95% CI: 1.23-10.85; p = 0.020; FDR q-value = 0.053), cigarette/hookah smoking (AOR: 3.65, 95% CI: 1.23, 10.85; p = 0.020; FDR q-value = 0.053) and lower age at first intercourse (AOR: 1.16, 95% CI: 1.05, 1.28; p = 0.004; FDR q-value = 0.048). The odds of BV was 0.80 and 0.78 times lower in participants who had coitus interruptus (AOR: 0.20, 95% CI: 0.06, 0.63; p = 0.006; FDR q-value = 0.048) and condom use (AOR: 0.28, 95% CI: 0.10, 0.79; p = 0.016; FDR q-value = 0.051), respectively, compared to participants who did not use contraceptives. CONCLUSION These findings suggested that lower serum vitamin D levels were associated with an increased risk of developing BV. However, further studies are needed to confirm the results of the present study.
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Affiliation(s)
- Seyede Faezeh Mojtahedi
- Student Research Committee, Faculty of Medicine, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Alireza Mohammadzadeh
- Department of Microbiology, Faculty of Medicine, Infectious Diseases Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Fatemeh Mohammadzadeh
- School of health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Jelveh Jalili Shahri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Narjes Bahri
- Department of Midwifery, Faculty of Medicine, Social Determinants of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran.
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Gigi RMS, Buitrago-Garcia D, Taghavi K, Dunaiski CM, van de Wijgert JHHM, Peters RPH, Low N. Vulvovaginal yeast infections during pregnancy and perinatal outcomes: systematic review and meta-analysis. BMC Womens Health 2023; 23:116. [PMID: 36944953 PMCID: PMC10029297 DOI: 10.1186/s12905-023-02258-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/06/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Vulvovaginal yeast infections in pregnancy are common and can cause extensive inflammation, which could contribute to adverse pregnancy outcomes. Symptomatic yeast infections are likely to cause more inflammation than asymptomatic. The objective of this study was to investigate associations between symptomatic and asymptomatic vulvovaginal yeast infections in pregnancy and perinatal outcomes. METHODS We did a systematic review and searched eight databases until 01 July 2022. We included studies reporting on pregnant women with and without laboratory confirmed vulvovaginal yeast infection and preterm birth or eight other perinatal outcomes. We used random effects meta-analysis to calculate summary odds ratios (OR), 95% confidence intervals (CI) and prediction intervals for the association between yeast infection and outcomes. We described findings from studies with multivariable analyses. We assessed the risk of bias using published tools. RESULTS We screened 3909 references and included 57 studies. Only 22/57 studies reported information about participant vulvovaginal symptoms. Preterm birth was an outcome in 35/57 studies (49,161 women). In 32/35 studies with available data, the summary OR from univariable analyses was 1.01 (95% CI 0.84-1.21, I2 60%, prediction interval 0.45-2.23). In analyses stratified by symptom status, we found ORs of 1.44 (95% CI 0.92-2.26) in two studies with ≥ 50% symptomatic participants, 0.84 (95% CI 0.45-1.58) in seven studies with < 50% symptomatic participants, and 1.12 (95% CI 0.94-1.35) in four studies with asymptomatic participants. In three studies with multivariable analysis, adjusted ORs were greater than one but CIs were compatible with there being no association. We did not find associations between vulvovaginal yeast infection and any secondary outcome. Most studies were at high risk of bias in at least one domain and only three studies controlled for confounding. CONCLUSIONS We did not find strong statistical evidence of an increased risk for preterm birth or eight other adverse perinatal outcomes, in pregnant women with either symptomatic or asymptomatic vulvovaginal yeast infection. The available evidence is insufficient to make recommendations about testing and treatment of vulvovaginal yeast infection in pregnancy. Future studies should assess vulvovaginal symptoms, yeast organism loads, concomitant vaginal or cervical infections, and microbiota using state-of-the-art diagnostics. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020197564.
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Affiliation(s)
- Ranjana M S Gigi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Research Unit, Foundation for Professional Development, East London, South Africa
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Diana Buitrago-Garcia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Katayoun Taghavi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Cara-Mia Dunaiski
- School of Health Sciences, Namibia University of Sciences and Technology, Windhoek, Namibia
| | - Janneke H H M van de Wijgert
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Remco P H Peters
- Research Unit, Foundation for Professional Development, East London, South Africa
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
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Salmanov AG, Netskar IP, Kostikov VV, Korniyenko SM, Artyomenko V, Rud VO, Kovalyshyn OA, Zarichanska K. VULVOVAGINAL CANDIDIASIS AFTER GYNECOLOGICAL SURGERIES AND ADVERSE PREGNANCY OUTCOME IN UKRAINE: A MULTICENTRE STUDY. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:2556-2563. [PMID: 38290017 DOI: 10.36740/wlek202312102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE The aim: To investigate the epidemiology and microbiology of vulvovaginal candidiasis (VVC) after gynecological surgeries, and adverse pregnancy outcomes in Ukraine. PATIENTS AND METHODS Materials and methods: Multicenter prospective cohort study was conducted from January 2020 to December 2022 and recruited pregnant and non-pregnant women aged 15-65 years who had sought medical help for vaginal dysbiosis the seven medical clinic from five regions of Ukraine. RESULTS Results: Between 2020 and 2022, 2,341 women were followed in gynecological practices, and 1,056 (41.5%) women were diagnosed with VVC during the same period. Of the total VVC cases, 31.9% were in non-pregnant and 68.1% in pregnant women. The use of antibiotics (OR=3.48), use hormonal contracep¬tives (OR=2.75) and pregnancy (OR=1.13) were associated with an increase in the risk of VVC diagnosis. Diabetes mellitus (OR=0.44) were additional risk factors. The most common pathogen of VVC was C. albicans, Nakaseomyces glabratus (C. glabrata), followed by Pichia kudriavzevii (C. krusei), C. parapsilosis, C. tropicalis, C. kefyr, C. guillieromondii, C. lusitaniae, and C. rugosa. We found no significant difference in adverse pregnancy outcomes between Candida-positive and Candida-negative women. CONCLUSION Conclusions: Vulvovaginal candidiasis after gynecological surgeries in Ukraine is a common medical problem in women that is associated with significant morbidity, and hence frequent medical visits. High prevalence rate of vulvovaginal candidiasis in the present study warrants, the importance of conducting continuous epidemiological surveys to measure changes in species distribution from C. albicans to non-albicans Candida species in Ukraine.
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Affiliation(s)
- Aidyn G Salmanov
- SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV, UKRAINE; INSTITUTE OF PEDIATRICS, OBSTETRICS AND GYNECOLOGY OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE, KYIV, UKRAINE
| | - Iryna P Netskar
- SHUPYK NATIONAL HEALTHCARE UNIVERSITY OF UKRAINE, KYIV, UKRAINE
| | | | | | | | - Victor O Rud
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
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Noormohammadi M, Eslamian G, Kazemi SN, Rashidkhani B. Association between dietary patterns and bacterial vaginosis: a case-control study. Sci Rep 2022; 12:12199. [PMID: 35842517 PMCID: PMC9288476 DOI: 10.1038/s41598-022-16505-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Bacterial vaginosis (BV) is a predominant vaginal disturbance that affects about 25% of childbearing-aged women. Dietary consumption may have a crucial role in vaginal flora imbalances. This study was a hospital-based case–control study. In total, 144 incident BV cases and 151 healthy participants were recruited from the gynecology clinic in Tehran, Iran, between November 2020 and June 2021. Participants' typical diets were collected by a food frequency questionnaire. Vaginal flora was characterized based on the Amsel criteria. Factor analysis was used to pinpoint the principal dietary patterns. For logistic regression, the first tertile was assumed as a reference. Five principal dietary patterns emerged and were nominated as "Healthy diet," "Unhealthy diet," "Ovo-vegetarian diet," "Pseudo-Mediterranean diet," and "Western diet." The "Unhealthy diet" pattern were positively associated with BV (adjusted odds ratio (aOR) = 3.35; 95% confidence interval (CI) 1.41, 7.94; ptrend: 0.006), while adherence to the "Ovo-vegetarian diet" pattern was associated with a reduced odds of BV (aOR = 0.16; 95% CI 0.07, 0.34; ptrend < 0.001). These results provide evidence that following the "unhealthy diet" pattern may lead to developing BV, and plant-based eating patterns may be associated with reduced BV odds.
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Affiliation(s)
- Morvarid Noormohammadi
- Department of Cellular and Molecular Nutrition, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, No 7, Hafezi St., Farahzadi Blvd., P.O.Box: 19395-4741, Tehran, 1981619573, Iran
| | - Ghazaleh Eslamian
- Department of Cellular and Molecular Nutrition, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, No 7, Hafezi St., Farahzadi Blvd., P.O.Box: 19395-4741, Tehran, 1981619573, Iran.
| | - Seyyedeh Neda Kazemi
- Department of Obstetrics and Gynecology, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahram Rashidkhani
- Department of Community Nutrition, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Association of Dietary Glycemic Index, Glycemic Load, Insulin Index, and Insulin Load with Bacterial Vaginosis in Iranian Women: A Case-Control Study. Infect Dis Obstet Gynecol 2022; 2022:1225544. [PMID: 35370395 PMCID: PMC8970957 DOI: 10.1155/2022/1225544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 03/16/2022] [Indexed: 12/21/2022] Open
Abstract
Background Inconsistent findings have been reported for associations between dietary indices and bacterial vaginosis (BV). The aim of this study was to examine the association of dietary glycemic index (DGI), glycemic load (DGL), insulin index (DII), and insulin load (DIL) with BV among Iranian women. Methods The current case-control study consisted of 144 new cases of BV and 151 controls. The diagnosis of BV was made based on the Amsel criterion in hospital clinics in Tehran, Iran, from November 2020 until June 2021. DGI, DGL, DII, and DIL were calculated from a validated semiquantitative food frequency questionnaire. The association between dietary carbohydrate indices and odds of BV were assessed adjusting for potential confounders through an estimation of two multivariate regression models. Results The multivariate adjusted odds ratio (OR) comparing the highest tertile of dietary DGI and DGL with the lower tertile was 2.99 (95% confidence interval (CI): 1.47–6.81; Ptrend = 0.003) and 4.01 (95% CI: 1.22–5.91; Ptrend = 0.029), respectively. In a fully adjusted model, the top tertile of dietary fiber compared to the bottom was associated with 88% (95% CI: 0.14-0.33) lower odds of BV (Ptrend < 0.001). DII and DIL were not significantly associated with odds of BV in both crude and adjusted regression models. Conclusion The findings support the hypothesis of moderate, direct associations between DGI or DGL and BV. Also, a diet high in fiber decreases odds of BV.
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Afifirad R, Darb Emamie A, Golmoradi Zadeh R, Asadollahi P, Ghanavati R, Darbandi A. Effects of Pro/Prebiotics Alone over Pro/Prebiotics Combined with Conventional Antibiotic Therapy to Treat Bacterial Vaginosis: A Systematic Review. Int J Clin Pract 2022; 2022:4774783. [PMID: 35685517 PMCID: PMC9159122 DOI: 10.1155/2022/4774783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Bacterial vaginosis (BV), caused by an imbalance in the vaginal microbiota, can be treated and prevented by probiotics. Pregnant women with BV can experience premature labor and spontaneous abortions. Probiotics and prebiotics promote the proliferation of beneficial microorganisms, alter the composition of the vaginal microbiota, and prevent intravaginal infections in postmenopausal women. In addition to reducing infection symptoms, pre/probiotics can also help prevent vaginal infections. MATERIALS AND METHODS A systematic review was conducted on studies from 2010 to 2020 to determine the efficacy of pre/probiotics on the treatment of BV in pregnant and nonpregnant women. The databases Medline, Scopus, Embase, and Google Scholar were systematically searched using the following keywords: "bacterial vaginosis," "probiotics," "prebiotics," and "synbiotics." RESULTS A total of 1,871 articles were found in the initial search, and 24 clinical trials were considered eligible. In studies comparing the effects of pre/probiotics and placebos with or without antibiotic therapy in patients with BV, significant differences in clinical outcomes were observed. Probiotics reduced the levels of IL-1β and IL-6, as well as the overall Nugent score and Amsel's criteria for restitution of a balanced vaginal microbiota. In addition, probiotics can reduce the vaginal colonization of Group B streptococci among pregnant women. In subjects treated with probiotics, BV cure rates were higher than those in subjects treated with antibiotics. There were no additional adverse events. CONCLUSION Pre/probiotic regimens, when used for BV treatment, are usually safe and can exhibit long-term and short-term benefits. In order to prove the benefits of pre/probiotics in BV treatment, additional high-quality research is required.
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Affiliation(s)
- Roghayeh Afifirad
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Darb Emamie
- Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Rezvan Golmoradi Zadeh
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Microbial Biotechnology Research Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Parisa Asadollahi
- Department of Microbiology, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | | | - Atieh Darbandi
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Microbial Biotechnology Research Centre, Iran University of Medical Sciences, Tehran, Iran
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Aduloju OP, Akintayo AA, Aduloju T. Prevalence of bacterial vaginosis in pregnancy in a tertiary health institution, south western Nigeria. Pan Afr Med J 2019; 33:9. [PMID: 31303954 PMCID: PMC6607451 DOI: 10.11604/pamj.2019.33.9.17926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/27/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of child bearing age. Bacterial vaginosis has emerged as a global health issue due to the adverse outcome in pregnancy and in the puerperium. The study determined the prevalence of BV and outcome of delivery among pregnant women. Methods Socio-demographic data and vaginal swab samples were obtained from 362 consecutive pregnant women with abnormal vaginal discharge attending antenatal clinic in Ekiti State University Teaching Hospital, Ado-Ekiti. Data were analysed using SPSS statistical software 21 and association between variables was compared using Chi square. Results The prevalence of BV among pregnant women with abnormal vaginal discharge in this study was 16.6%. Age group 25-34yrs, multiparity and higher education were significantly associated with BV, p < 0.05. Symptoms such as vulvar itching, dyspareunia, lower abdominal pains and characteristic of vaginal discharge such as colour and consistency were significantly associated with BV, p < 0.05. Women with bacterial vaginosis significantly had prelabour rupture of fetal membrane and their babies were born prematurely with low birth weight and Apgar score of less than 5 at one minute, p < 0.05. However, there was no difference statistically in rate of admission into special care baby unit among the women, p > 0.05. Conclusion The findings of this study suggest that there should be screening for BV in pregnant women presenting with abnormal vaginal discharge so that they could be treated accordingly. This will mitigate the complications arising from bacterial vaginosis.
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Affiliation(s)
- Olusola Peter Aduloju
- Department of Obstetrics and Gynaecology, Ekiti State University, Ado-Ekiti, Nigeria
| | | | - Tolulope Aduloju
- Medical Social Services Department, Ekiti State University Teaching Hospital Ado-Ekiti, Nigeria
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Marín E, Haesaert A, Padilla L, Adán J, Hernáez ML, Monteoliva L, Gil C. Unraveling Gardnerella vaginalis Surface Proteins Using Cell Shaving Proteomics. Front Microbiol 2018; 9:975. [PMID: 29867878 PMCID: PMC5962675 DOI: 10.3389/fmicb.2018.00975] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/25/2018] [Indexed: 12/17/2022] Open
Abstract
Gardnerella vaginalis is one of the main etiologic agents of bacterial vaginosis (BV). This infection is responsible for a wide range of public health costs and is associated with several adverse outcomes during pregnancy. Improving our understanding of G. vaginalis protein cell surface will assist in BV diagnosis. This study represents the first proteomic approach that has analyzed the exposed proteins on G. vaginalis cell surface using a shaving approach. The 261 G. vaginalis proteins identified using this approach were analyzed with bioinformatic tools to detect characteristic motifs from surface-exposed proteins, such as signal peptides (36 proteins), lipobox domains (17 proteins), LPXTG motifs (5 proteins) and transmembrane alpha-helices (66 proteins). One third of the identified proteins were found to have at least one typical motif of surface-exposed proteins. Furthermore, the subcellular location was examined using two predictors (PSORT and Gpos-mPLoc). These bioinformatic tools classified 17% of the identified proteins as surface-associated proteins. Interestingly, we identified 13 members of the ATP-binding cassette (ABC) superfamily, which were mainly involved in the translocation of various substrates across membranes. To validate the location of the G. vaginalis surface-exposed proteins, an immunofluorescence assay with antibodies against Escherichia coli GroEL was performed to reveal the extracellular location of the moonlighting GroEL. In addition, monoclonal antibodies (mAb) against G. vaginalis Cna protein were produced and used to validate the location of Cna on the surface of the G. vaginalis. These high affinity anti-Cna mAb represent a useful tool for the study of this pathogenic microorganism and the BV.
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Affiliation(s)
- Elvira Marín
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| | - Annelies Haesaert
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| | - Laura Padilla
- Health and Biomed Division, LEITAT Technological Center, Barcelona, Spain
| | - Jaume Adán
- Health and Biomed Division, LEITAT Technological Center, Barcelona, Spain
| | - María L Hernáez
- Unidad de Proteómica, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain
| | - Lucía Monteoliva
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Concha Gil
- Departamento de Microbiología y Parasitología, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain.,Unidad de Proteómica, Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
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