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Micks E, Reed SD, Mitchell C. The Postmenopausal Vaginal Microbiome and Genitourinary Syndrome of Menopause. Clin Obstet Gynecol 2024; 67:79-88. [PMID: 38032828 PMCID: PMC10873068 DOI: 10.1097/grf.0000000000000832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
This review summarizes our current understanding of associations of the postmenopausal vaginal microbiome with genitourinary syndrome of menopause. We review the normal postmenopausal microbiota, examine the association of the microbiome with vulvovaginal symptoms, describe microbial communities associated with physical and laboratory findings, and report the impact of different treatments for genitourinary syndrome of menopause on microbiota and symptom improvement. Postmenopausal vaginal symptoms have an underlying pathophysiology that has not been fully elucidated. Estrogen treatment may not be sufficient to relieve symptoms of vaginal discomfort in all postmenopausal individuals. In addition, other interventions targeted at changing the microbiota or pH do not consistently improve symptom severity.
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Affiliation(s)
- Elizabeth Micks
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington
| | - Susan D Reed
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington
| | - Caroline Mitchell
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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2
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Toader DO, Olaru RA, Iliescu DG, Petrita R, Calancea FL, Petre I. Clinical Performance and Safety of Vaginal Ovules in the Local Treatment of Nonspecific Vaginitis: A National, Multicentric Clinical Investigation. Clin Ther 2023; 45:873-880. [PMID: 37474354 DOI: 10.1016/j.clinthera.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 06/06/2023] [Accepted: 06/27/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Nonspecific vaginitis is a distinct clinical entity with particular microscopic and immunologic features. There is currently no standard of care for women with nonspecific vaginitis. The aim of our study was to assess the change in vaginal symptoms score after 3 months of treatment with an intravaginal medical device in participants with abnormal vaginal discharge and specific signs and symptoms. As secondary objectives, the study analyzed other clinical and microscopic features, such as vaginal discharge aspect, change in vaginal pH, change in vaginal microbiome, and vaginal inflammation. METHODS The study population included 47 participants with symptomatic vulvovaginitis, distinct from candidiasis, trichomoniasis, or bacterial vaginosis. The study design included 2 research sites from Romania. The treatment protocol consisted of 1 ovule per day inserted intravaginally during 15 consecutive days. The total study duration was 3 months. FINDINGS The intravaginal medical device had a positive impact on the vaginal symptoms score for 72.34% of the study participants. Topical administration of the ovules balanced vaginal pH values and significantly reduced signs of inflammation between study visits. IMPLICATIONS This intravaginal medical device had curative effects that support its use as a stand-alone treatment in women with nonspecific vaginitis. A second clinical investigation is ongoing to evaluate the clinical efficacy of the device in postoperative care of cervical and vaginal wounds traumatic or secondary to surgical interventions. CLINICALTRIALS gov identifier: NCT04735705.
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Affiliation(s)
- Daniela Oana Toader
- Department of Obstetrics and Gynecology III, Institutul National pentru Sanatatea Mamei si Copilului Alessandrescu Rusescu, Clinic of Obstetrics and Gynecology Polizu, Bucharest, Romania; Discipline of Obstetrics, Gynecology, and Neonatology, Spitalul Clinic Polizu "Carol Davila," University of Medicine and Pharmacy Bucharest, Bucharest, Romania
| | - Raluca Alexandra Olaru
- Department of Obstetrics and Gynecology III, Institutul National pentru Sanatatea Mamei si Copilului Alessandrescu Rusescu, Clinic of Obstetrics and Gynecology Polizu, Bucharest, Romania; Discipline of Obstetrics, Gynecology, and Neonatology, Spitalul Clinic Polizu "Carol Davila," University of Medicine and Pharmacy Bucharest, Bucharest, Romania
| | - Dominic-Gabriel Iliescu
- Discipline of Obstetrics and Gynecology VIII, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | | | | | - Izabella Petre
- Discipline of Obstetrics and Gynecology XII, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
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Powell AM, Sarria I, Goje O. Microbiome and Vulvovaginitis. Obstet Gynecol Clin North Am 2023; 50:311-326. [PMID: 37149312 DOI: 10.1016/j.ogc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Vulvovaginitis occurs in mostly reproductive aged women. Recurrent vaginitis affects overall quality of life, with a large financial burden on the patient, family, and health system. This review discusses a clinician's approach to vulvovaginitis with specific attention to the 2021 updated Center for Disease Control and Prevention guidelines. The authors discuss the role of the microbiome in vaginitis and evidence-based approaches for diagnosis and treatment of vaginitis. This review also provides updates on new considerations, diagnosis, management, and treatment of vaginitis. Desquamative inflammatory vaginitis and genitourinary syndrome of menopause are discussed as differential diagnosis of vaginitis symptoms.
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Affiliation(s)
- Anna Maya Powell
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 249, Baltimore, MD 21287, USA. https://twitter.com/annapbanana
| | - Isabella Sarria
- Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Oluwatosin Goje
- OB/GYN and Women's Health Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A81, Cleveland, OH 44195, USA.
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Eleutério J, Campaner AB, de Carvalho NS. Diagnosis and treatment of infectious vaginitis: Proposal for a new algorithm. Front Med (Lausanne) 2023; 10:1040072. [PMID: 36844222 PMCID: PMC9947655 DOI: 10.3389/fmed.2023.1040072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Abstract
Background Vaginitis is the most common gynecologic diagnosis in primary care, and most women have at least one episode during their lives. The need for standardized strategies to diagnose and treat vaginitis, both in primary care and among gynecologists, is emphasized. The Brazilian Group for Vaginal Infections (GBIV, acronym in Portuguese) aimed to update the practical approach to affected women by reviewing and discussing recent literature, and developing algorithms for diagnosis and treatment of vaginitis. Methods A literature search within biomedical databases PubMed and SCieLo was conducted in January 2022. The available literature was evaluated by three experienced researchers, members of the GBIV, to summarize the main data and develop practical algorithms. Results and conclusion Detailed algorithms were developed with the main goal to improve gynecological practice considering different scenarios and access to diagnostic tools, from the simplest to the most complex tests. Different age groups and specific contexts were also considered. The combination of anamnesis, gynecological examination, and complementary tests remains the basis of a proper diagnostic and therapeutic approach. Periodic updates of these algorithms are warranted as new evidence becomes available.
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Affiliation(s)
- José Eleutério
- Department of Health for Women, Children, and Adolescents, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil,*Correspondence: José Eleutério Jr.,
| | - Adriana Bittencourt Campaner
- Department of Gynecology and Obstetrics, Faculty of Medical Sciences of Santa Casa de São Paulo, São Paulo, Brazil
| | - Newton Sergio de Carvalho
- Department of Gynecology and Obstetrics, Infectious Diseases in Gynecology and Obstetrics Sector, Federal University of Paraná, Curitiba, Paraná, Brazil
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5
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Vempati YS, Sobel JD. Desquamative Inflammatory Vaginitis as an Expression of Systemic Lupus Erythematosus. J Low Genit Tract Dis 2022; 26:345-346. [PMID: 35795900 DOI: 10.1097/lgt.0000000000000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yogitha Sai Vempati
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
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6
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Marnach ML, Wygant JN, Casey PM. Evaluation and Management of Vaginitis. Mayo Clin Proc 2022; 97:347-358. [PMID: 35120697 DOI: 10.1016/j.mayocp.2021.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/15/2022]
Abstract
Vaginitis is a common concern for women across the lifespan. Vaginal symptoms may impact quality of life, and clinicians are challenged in the evaluation and management of bacterial vaginosis, Candida vaginitis, trichomoniasis, desquamative inflammatory vaginitis, and genitourinary syndrome of menopause.
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7
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Song M, Day T, Kliman L, Otton G, Yap D, Pagano R, Tan Y, Scurry J. Desquamative Inflammatory Vaginitis and Plasma Cell Vulvitis Represent a Spectrum of Hemorrhagic Vestibulovaginitis. J Low Genit Tract Dis 2022; 26:60-67. [PMID: 34928254 PMCID: PMC8719513 DOI: 10.1097/lgt.0000000000000637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to identify whether desquamative inflammatory vaginitis (DIV) and plasma cell vulvitis (PCV) are distinct clinicopathologic entities. MATERIALS AND METHODS The pathology database identified biopsies described as "vaginitis" or "vulvitis" occurring in nonkeratinized epithelium or mucocutaneous junction. Exclusions were age less than 18 years, unavailable slides or records, concurrent neoplasia, or histopathology consistent with other entities. Clinical data included demographics, symptoms, examination, microbiology, treatment, and response. Histopathologic review documented site, epithelial thickness and characteristics, infiltrate, and vascular abnormalities. Cases were analyzed according to histopathologic impression of DIV or PCV based on previous pathologic descriptions. RESULTS There were 36 specimens classified as DIV and 18 as PCV from 51 women with mean age of 51 years; 3 (6%) had concurrent biopsies with both. Pain was more common in PCV, but rates of discharge, itch, and bleeding were comparable. Rates of petechiae or erythema were similar and vaginal examination was abnormal in 72% of PCV cases. All DIV and 33% of PCV occurred in squamous mucosa; the remaining PCV cases were from mucocutaneous junction. Mean epithelial thickness, rete ridge appearance, exocytosis, and spongiosis were similar in DIV and PCV. Epithelial erosion, wide-diameter lesions, plasma cells, and stromal hemosiderin occurred in both but were more common in PCV. Lymphocyte-obscured basal layer, narrow-diameter lesions, hemorrhage, and vascular congestion were seen in both, but more common and marked in DIV. CONCLUSIONS Desquamative inflammatory vaginitis and PCV have overlapping symptoms, signs, and histopathologic features. They may represent a single condition of hemorrhagic vestibulovaginitis with varying manifestations according to location and severity.
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Affiliation(s)
- Myriarm Song
- Maternity and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Tania Day
- Maternity and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Len Kliman
- Epworth Freemasons Hospital, East Melbourne, Victoria, Australia
| | - Geoff Otton
- Maternity and Gynaecology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Desiree Yap
- Private practice, East Melbourne, Victoria, Australia
| | - Ross Pagano
- Vulvar Disorders and Dermatology Clinic, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Yasmin Tan
- Royal Hospital for Women, Sydney, New South Wales, Australia
| | - James Scurry
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
- Pathology NSW, Hunter New England, Newcastle, New South Wales, Australia
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Deka N, Hassan S, Seghal Kiran G, Selvin J. Insights into the role of vaginal microbiome in women's health. J Basic Microbiol 2021; 61:1071-1084. [PMID: 34763361 DOI: 10.1002/jobm.202100421] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/19/2021] [Accepted: 10/31/2021] [Indexed: 01/12/2023]
Abstract
The vaginal microbiome is a complex and dynamic microecosystem that fluctuates continually throughout a woman's life. Lactobacillus, a bacterium that possesses antibacterial properties dominates a healthy vaginal microbiome. Bacterial vaginosis is the most common vaginal disorder that has been linked with the dysbiosis of normal vaginal microbiota. Despite the importance of vaginal microbiome, little is known about functions it performs especially, how it helps in protecting the female reproductive tract. This knowledge gap is a significant impediment to the development of effective and feasible clinical treatments that might be required to improve women's health. Thus, a deeper understanding of the functional aspects and not just the composition of vaginal microbiome may aid in improving the diagnostics and treatment strategies. Recent advancement in molecular methods and computational biology have allowed researchers to acquire more knowledge about the vaginal microbiome. The use of metagenomics (culture-independent high-throughput technology) and bioinformatics tools have improved our understanding of the vaginal microbiome. In this review, we have attempted to explore the factors that may alter normal vaginal microbiota homeostasis such as age, sexual behavior, ethnicity, and hygiene, and so forth. We also discuss the role of probiotics in restoring healthy vaginal microbiome.
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Affiliation(s)
- Namrata Deka
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Saqib Hassan
- Division of Non-Communicable Diseases, Indian Council of Medical Research (ICMR), New Delhi, India.,Department of Microbiology, School of Life Sciences, Pondicherry University, Puducherry, India
| | - George Seghal Kiran
- Department of Food Science and Technology, School of Life Sciences, Pondicherry University, Puducherry, India
| | - Joseph Selvin
- Department of Microbiology, School of Life Sciences, Pondicherry University, Puducherry, India
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9
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Yockey L, Dowst S, Zonozi R, Huizenga N, Murphy P, Laliberte K, Rosenthal J, Niles JL, Mitchell CM. Inflammatory vaginitis in women on long-term rituximab treatment for autoimmune disorders. BMC WOMENS HEALTH 2021; 21:285. [PMID: 34353326 PMCID: PMC8340364 DOI: 10.1186/s12905-021-01423-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 07/07/2021] [Indexed: 12/04/2022]
Abstract
Background Consequences of long-term B cell depletion with rituximab are not well understood. We describe inflammatory vaginitis as a potential side effect of long-term rituximab treatment, distinct from previously described vulvovaginal pyoderma gangrenosum. Methods We performed a retrospective analysis of women treated with rituximab for more than 1 year to determine the prevalence and clinical characteristics of vaginitis cases. We conducted a case–control analysis with up to 3 controls for each vaginitis case. Results We identified sixteen inflammatory vaginitis cases. Women with vaginitis were age 23–68 (median 42), primarily being treated for ANCA-associated vasculitis (11/16; 69%). Most reported copious vaginal discharge (100%) and pain with sex (75%). All women with return of circulating B-cells to > 10 cells/mL had complete (5/9) or significant (4/9) improvement in symptoms. In case–control analysis there was no significant difference in length of B-cell depletion, immune parameters, creatinine levels, and history of neutropenia. Conclusion Inflammatory vaginitis is a potential side effect of prolonged continuous B cell depletion with rituximab. More studies are needed to characterize the incidence and etiology of vaginitis among women on long term rituximab therapy and establish a causal relationship.
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Affiliation(s)
- Laura Yockey
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Dowst
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Noah Huizenga
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick Murphy
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Karen Laliberte
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Jillian Rosenthal
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - John L Niles
- Division of Nephrology, Vasculitis and Glomerulonephritis Clinic, Massachusetts General Hospital, Boston, MA, USA
| | - Caroline M Mitchell
- Department of Obstetrics and Gynecology, Vincent Center for Reproductive Biology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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11
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Sonthalia S, Aggarwal P, Das S, Sharma P, Sharma R, Singh S. Aerobic vaginitis - An underdiagnosed cause of vaginal discharge - Narrative review. Int J STD AIDS 2020; 31:1018-1027. [PMID: 32842907 DOI: 10.1177/0956462420913435] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The concept of vaginal dysbiosis was for long considered synonymous with bacterial vaginosis (BV), which is characterized by a homogenous non-inflammatory vaginal discharge. The inflammatory variant of vaginal dysbiosis, called aerobic vaginitis (AV), has remained unknown to a large part of the global dermatology and venereology community, gynaecologists and reproductive tract infection specialists with consequential under diagnosis. AV significantly differs from BV, in clinical presentation, diagnostic criteria and management. The deleterious impact of untreated AV on pregnancy merits discussion. Understanding AV is also crucial for better comprehension of desquamative inflammatory vaginitis (DIV), the most severe form of the same entity. We review the condition's epidemiology, risk factors and suspected aetiology, symptoms and signs, and the latest evidence-backed approach to diagnosis and treatment. The ideal diagnostic approach and treatment for AV/DIV are yet to be established. The currently recommended diagnostic approach for AV/DIV merits an overhaul by incorporating changes to render it feasible for resource-constraint countries. The diagnostic criteria lack a uniform applicability in different physiological groups of women and cannot be used in postpartum or postmenopausal states at the same cut-off levels. Similarly, treatment guidelines merit a relook, and customization, given the equivocality of options suggested by different investigators.
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Affiliation(s)
- Sidharth Sonthalia
- Department of Dermatology & STD, Skinnocence: The Skin Clinic & Research Centre, Gurugram, India
| | - Parul Aggarwal
- Department of Dermatology & STD, First Point Medicentre, Gurugram, India
| | - Shukla Das
- Department of Microbiology, University College of Medical Sciences & GTB Hospital, New Delhi, India
| | - Poonam Sharma
- Department of Dermatology & STD, Skin Institute & School of Dermatology (SISD), New Delhi, India
| | - Rahul Sharma
- Department of Community Medicine, University College of Medical Sciences & GTB Hospital, New Delhi, India
| | - Sweety Singh
- Department of Microbiology, University College of Medical Sciences & GTB Hospital, New Delhi, India
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12
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Desquamative Inflammatory Vaginitis as an Extraintestinal Manifestation of Crohn’s Disease. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00733-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Noncandidal vaginitis: a comprehensive approach to diagnosis and management. Am J Obstet Gynecol 2020; 222:114-122. [PMID: 31513780 DOI: 10.1016/j.ajog.2019.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/16/2019] [Accepted: 09/03/2019] [Indexed: 11/20/2022]
Abstract
Vaginitis is one of the most common causes of patient visits to gynecologists, primary care providers, and urgent care centers. However, many women leave without a clear diagnosis or experience recurrent symptoms despite treatment. The 3 most common etiologies of vaginitis are trichomonas, bacterial vaginosis, and vulvovaginal candidiasis, which account for an estimated 70% of cases. The remaining 30% may be related to other causes of vaginitis, including atrophic vaginitis, desquamative inflammatory vaginitis, and vaginal erosive disease. The purpose of this review is to describe the noncandidal causes of acute and recurrent vaginitis, with the goal of improving the likelihood of accurate diagnosis as well as efficient and effective therapy. We excluded candidal vaginitis from our review because there was a recently published review on this topic in the Journal. The clinical presentation and evaluation of patients with symptoms of vaginitis can be triaged into 1 of 2 diagnostic pathways: noninflammatory and inflammatory vaginitis. The most common noninflammatory cause is bacterial vaginosis. Features such as irritation, purulent discharge, and the presence of polymorphonuclear neutrophils are more suggestive of an inflammatory process. Trichomoniasis is the most common cause of inflammatory vaginitis. Other well-described forms of inflammatory vaginitis include atrophic vaginitis, desquamative inflammatory vaginitis, and erosive disease. We present a review of the pathogenesis, symptoms, examination findings, diagnostic testing, and treatment for each of these causes of noncandidal vaginitis.
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Kalia N, Singh J, Kaur M. Microbiota in vaginal health and pathogenesis of recurrent vulvovaginal infections: a critical review. Ann Clin Microbiol Antimicrob 2020; 19:5. [PMID: 31992328 PMCID: PMC6986042 DOI: 10.1186/s12941-020-0347-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/22/2020] [Indexed: 12/13/2022] Open
Abstract
Recurrent vulvovaginal infections (RVVI) has not only become an epidemiological and clinical problem but also include large social and psychological consequences. Understanding the mechanisms of both commensalism and pathogenesis are necessary for the development of efficient diagnosis and treatment strategies for these enigmatic vaginal infections. Through this review, an attempt has been made to analyze vaginal microbiota (VMB) from scratch and to provide an update on its current understanding in relation to health and common RVVI i.e. bacterial vaginosis, vulvovaginal candidiaisis and Trichomoniasis, making the present review first of its kind. For this, potentially relevant studies were retrieved from data sources and critical analysis of the literature was made. Though, culture-independent methods have greatly unfolded the mystery regarding vaginal bacterial microbiome, there are only a few studies regarding the composition and diversity of vaginal mycobiome and different Trichomonas vaginalis strains. This scenario suggests a need of further studies based on comparative genomics of RVVI pathogens to improve our perceptive of RVVI pathogenesis that is still not clear (Fig. 5). Besides this, the review details the rationale for Lactobacilli dominance and changes that occur in healthy VMB throughout a women's life. Moreover, the list of possible agents continues to expand and new species recognised in both health and VVI are updated in this review. The review concludes with the controversies challenging the widely accepted dogma i.e. "VMB dominated with Lactobacilli is healthier than a diverse VMB". These controversies, over the past decade, have complicated the definition of vaginal health and vaginal infections with no definite conclusion. Thus, further studies on newly recognised microbial agents may reveal answers to these controversies. Conversely, VMB of women could be an answer but it is not enough to just look at the microbiology. We have to look at the woman itself, as VMB which is fine for one woman may be troublesome for others. These differences in women's response to the same VMB may be determined by a permutation of behavioural, cultural, genetic and various other anonymous factors, exploration of which may lead to proper definition of vaginal health and disease.
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Affiliation(s)
- Namarta Kalia
- Department of Molecular Biology & Biochemistry, Guru Nanak Dev University, Amritsar, 143005 India
| | - Jatinder Singh
- Department of Molecular Biology & Biochemistry, Guru Nanak Dev University, Amritsar, 143005 India
| | - Manpreet Kaur
- Department of Human Genetics, Guru Nanak Dev University, Amritsar, 143005 India
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15
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De Seta F, Comar M, Guaschino S, Larsen B. Bacterial Vaginitis and Vaginosis. Sex Transm Infect 2020. [DOI: 10.1007/978-3-030-02200-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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16
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De Seta F, Campisciano G, Zanotta N, Ricci G, Comar M. The Vaginal Community State Types Microbiome-Immune Network as Key Factor for Bacterial Vaginosis and Aerobic Vaginitis. Front Microbiol 2019; 10:2451. [PMID: 31736898 PMCID: PMC6831638 DOI: 10.3389/fmicb.2019.02451] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/11/2019] [Indexed: 01/19/2023] Open
Abstract
Regarding bacterial vaginosis (BV), the relevance of the vaginal microbiota to the women’s health fulfills a key role, but knowledge gaps regarding aerobic vaginitis (AV) exist. This study aims to characterize vaginal microbiome and its relationship with the local immune mediators, providing an opportunity to define the link between vaginal commensal microorganisms and opportunistic pathogens in the relation of a given vaginal community state type (CST). A total of 90 vaginal samples from Caucasian asymptomatic women of reproductive age (18–40 years) attending the yearly examination and not reporting any vaginal complaints were retrospectively evaluated for microbiome assessment and immune factor dosage. The samples were tested by the Ion Torrent PGM and the Luminex Bio-Plex technologies for the analysis of microbiome and immune factors, respectively. In our study, the CST classification together with the local immune response profiling represented a good predictive indicator of the vaginal health, suggesting that the predominance of a specific Lactobacillus and its relative abundance are pivotal elements to maintain a physiologic status. A vaginal colonization from Bifidobacterium may absolve a protective role similar to that of Lactobacillus, corresponding to a newly identified CST, although studies are needed to better clarify its clinical significance. Moreover, within each CST, a different pattern of inflammation is activated and orchestrated both by the dominant Lactobacillus spp. and by specific non-Lactobacillus bacteria and can give insights into the pathogenic mechanisms. In conclusion, this study contributes to the characterization of vaginal dysbiosis, reshaping this concept by taking into consideration the CST profiling, local immune marker, and immune–microbial network.
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Affiliation(s)
- Francesco De Seta
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Nunzia Zanotta
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | - Giuseppe Ricci
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Manola Comar
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
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Reichman O, Margesson LJ, Rasmussen CA, Lev-Sagie A, Sobel JD. Algorithms for Managing Vulvovaginal Symptoms-a Practical Primer. Curr Infect Dis Rep 2019; 21:40. [PMID: 31595345 DOI: 10.1007/s11908-019-0693-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW To present a comprehensive systematic approach for diagnosing correctly the cause(s) of bothersome genital symptoms. RECENT FINDINGS We searched the PUBMED for practical clinical guidelines, written by a multidisciplinary team of healthcare providers directed for diagnosing bothersome genital symptoms. This search was performed by a professional information specialist using the keywords "vulvovaginal," "vulvar," "multidisciplinary diagnosis," "interdisciplinary consultation," and "vulvology." We found numerous publications defining the criteria for diagnosing specific disorders, but only a few publications presented a multidisciplinary clinical algorithm for diagnosing bothersome vulvovaginal symptoms. The authors, from three different specialities, gathered together (online), in aim to present a comprehensive systematic approach for accurate diagnosing of bothersome vulvovaginal symptoms. Six principles for accurately diagnosing a woman with bothersome genital symptoms were endorsed: (1) locate the discomfort (vulva, clitoris, vestibule, vagina, cervix, pelvis); (2) consider more than one entity; (3) evaluate each symptom separately (it is common to have more than one entity necessitating treatment for each); (4) use pH and wet mount microscopy; (5) obtain a follow-up visit in 2-4 weeks; (6) perform a biopsy for dermatological conditions that are resistant to treatment.
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Affiliation(s)
- Orna Reichman
- Division of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel. .,Division - OBGYN, Shaare Ze[dek Medical Center, Hebrew University Medical School, Jerusalem, Israel.
| | - Lynette J Margesson
- Department of Obstetrics & Gynecology and Surgery (Dermatology), Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Cynthia A Rasmussen
- Obstetrics Gynecology & Repro. Biology, Beth Israel Deaconess Medical Center, Harvard Vanguard Medical Associates, Burlington, MA, USA
| | - Ahinoam Lev-Sagie
- Vulvovaginal Disorders Clinic, Clalit Health Organization, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Abstract
The spread of sexually transmitted infections (STIs) remains a significant public health issue in the United States. Social, economic, and behavioral implications affecting the spread of STIs have been identified. The most important social factor in the United States is the stigma associated with discussing sex and STI screening. In this article, specific recommendations for women are included regarding screening, diagnosing, and treating common vaginal and cervical infections. Screening women for infections of the vagina and cervix is essential because untreated infections may result in complications that have current and long-term health consequences and impact quality of life.
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Affiliation(s)
- Ashley L Hodges
- Department of Family, Community, and Health Systems, University of Alabama at Birmingham School of Nursing, 1701 University Boulevard, Birmingham, AL 35294-1210, USA.
| | - Aimee Chism Holland
- Department of Family, Community, and Health Systems, University of Alabama at Birmingham School of Nursing, 1701 University Boulevard, Birmingham, AL 35294-1210, USA
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Affiliation(s)
- Jorma Paavonen
- From the Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki (J.P.); and the Department of Medicine, University of British Columbia, Vancouver, Canada (R.C.B.)
| | - Robert C Brunham
- From the Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki (J.P.); and the Department of Medicine, University of British Columbia, Vancouver, Canada (R.C.B.)
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20
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Polymeric gels for intravaginal drug delivery. J Control Release 2018; 270:145-157. [DOI: 10.1016/j.jconrel.2017.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 12/14/2022]
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Donders GGG, Bellen G, Grinceviciene S, Ruban K, Vieira-Baptista P. Aerobic vaginitis: no longer a stranger. Res Microbiol 2017; 168:845-858. [PMID: 28502874 DOI: 10.1016/j.resmic.2017.04.004] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
Aerobic vaginitis (AV) is the name given in 2002 to a vaginal infectious entity which was not recognized as such before. It is characterized by abnormal (dysbiotic) vaginal microflora containing aerobic, enteric bacteria, variable levels of vaginal inflammation and deficient epithelial maturation. Although AV and bacterial vaginosis (BV) share some characteristics, such as a diminished number or absence of lactobacilli, increased discharge (fishy smelling in BV, while in severe forms of AV, a foul, rather rotten smell may be present) and increased pH (often more pronounced in AV), there are also striking differences between the two. There is no inflammation in women with BV, whereas the vagina of women with AV often appears red and edematous, and may even display small erosions or ulcerations. The color of the discharge in BV is usually whitish or gray and of a watery consistency, whereas in AV it is yellow to green and rather thick and mucoid. Women with BV do not have dyspareunia, while some women with severe AV do. Finally, the microscopic appearance differs in various aspects, such as the presence of leucocytes and parabasal or immature epithelial cells in AV and the absence of the granular aspect of the microflora, typical of BV. Despite all these differences, the distinction between AV and BV was not recognized in many former studies, leading to incomplete and imprecise diagnostic workouts and erroneous management of patients in both clinical and research settings. The prevalence of AV ranges between 7 and 12%, and is therefore less prevalent than BV. Although still largely undiagnosed, many researchers and clinicians increasingly take it into account as a cause of symptomatic vaginitis. AV can co-occur with other entities, such as BV and candidiasis. It can be associated with dyspareunia, sexually transmitted infections (such as human papilloma virus, human immunodeficiency virus, Trichomonas vaginalis and Chlamydia trachomatis), chorioamnionitis, fetal infection, preterm birth and cervical dysplasia. Many other possible pathological associations are currently under investigation. The diagnosis of AV is made using wet mount microscopy, ideally using phase contrast. An AV score is calculated, according to: lactobacillary grade, presence of inflammation, proportion of toxic leucocytes, characteristics of the microflora and presence of immature epithelial cells. To circumvent the hurdle of microscopic investigation, some groups have begun to develop nucleic-acid-based and enzymatic diagnostic tests, but the detailed information obtained with phase contrast microscopy is irreplaceable. The best treatment is not yet fully determined, but it must be tailored according to the microscopic findings and the patient's needs. There is a role for local estrogen therapy, corticosteroids, antimicrobials and probiotics. Further research will reveal more precise data on diagnosis, pathogenesis, management and prevention.
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Affiliation(s)
- Gilbert G G Donders
- Femicare vzw, Tienen, Belgium; Department of Obstetrics & Gynaecology, Antwerp University, Antwerp, Belgium.
| | | | - Svitrigaile Grinceviciene
- Femicare vzw, Tienen, Belgium; Vilnius University, Institute of Biotechnology, Department of Biothermodynamics and Drug Design, Vilnius, Lithuania
| | | | - Pedro Vieira-Baptista
- Department of Gynaecology and Obstetrics, Centro Hospitalar de São João, Porto, Portugal
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Mitchell L, King M, Brillhart H, Goldstein A. Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. Sex Med 2017; 5:e212-e214. [PMID: 28460993 PMCID: PMC5562466 DOI: 10.1016/j.esxm.2017.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/20/2017] [Accepted: 03/16/2017] [Indexed: 10/29/2022] Open
Abstract
Desquamative inflammatory vaginitis is a poorly understood chronic vaginitis with an unknown etiology. Symptoms of desquamative inflammatory vaginitis include copious yellowish discharge, vulvovaginal discomfort, and dyspareunia. Cervical ectropion, the presence of glandular columnar cells on the ectocervix, has not been reported as a cause of desquamative inflammatory vaginitis. Although cervical ectropion can be a normal clinical finding, it has been reported to cause leukorrhea, metrorrhagia, dyspareunia, and vulvovaginal irritation. Patients with cervical ectropion and desquamative inflammatory vaginitis are frequently misdiagnosed with candidiasis or bacterial vaginosis and repeatedly treated without resolution of symptoms. We report the case of a 34-year-old woman with a 4-year history of profuse yellowish discharge and dyspareunia. Upon presentation, her symptoms and laboratory results met the criteria for desquamative inflammatory vaginitis, but the standard treatments did not provide long-lasting relief. As a last resort, cryotherapy (cryosurgery) of her cervix was performed for treatment of her cervical ectropion, which provided complete resolution of her symptoms. Mitchell L, King M, Brillhart H, Goldstein A. Cervical Ectropion May Be a Cause of Desquamative Inflammatory Vaginitis. Sex Med 2017;5:e212-e214.
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Affiliation(s)
- Leia Mitchell
- The Centers for Vulvovaginal Disorders, Washington, DC, and New York, NY, USA.
| | - Michelle King
- The Centers for Vulvovaginal Disorders, Washington, DC, and New York, NY, USA; Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Heather Brillhart
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andrew Goldstein
- The Centers for Vulvovaginal Disorders, Washington, DC, and New York, NY, USA; George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Hum M, Dytoc M. A Dermatologist’s Approach to Genitourinary Syndrome of Menopause. J Cutan Med Surg 2017; 21:418-424. [DOI: 10.1177/1203475417708165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Genitourinary syndrome of menopause (GSM) is a debilitating condition caused by hypoestrogenism that presents with vaginal dryness and dyspareunia as well as other genital, sexual, and urinary symptoms. Previously known as atrophic vaginitis, the term GSM is now used. Objective: To help familiarise dermatologists with diagnosing and managing GSM. Methods: In total, 218 articles were identified and reviewed by 2 independent authors using PubMed. Articles included were from December 2005 to December 2015. Sixty-seven articles met our inclusion criteria. Results: GSM is a clinical diagnosis, requiring the presence of symptoms that should be bothersome and not accounted for by another condition. A pH test may help with diagnosis as vaginal pH will be increased from acidic to neutral. The Papanicolaou test is not recommended because of poor clinical correlation. First-line treatment is low-dose local vaginal estrogen therapy, which has proven efficacy and safety. Serum estrogen levels are not significantly affected with the exception of creams containing high-dose conjugated equine estrogens. Other options have yet to be approved for use in Canada but show promise. Conclusion: GSM is a debilitating and common condition that suffers from barriers to diagnosis and treatment. Current treatments are well tolerated, rewarding, and effective with rapid onset.
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Affiliation(s)
- Matthew Hum
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marlene Dytoc
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada
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Donders GGG, Ruban K, Bellen G. Selecting anti-microbial treatment of aerobic vaginitis. Curr Infect Dis Rep 2015; 17:477. [PMID: 25896749 DOI: 10.1007/s11908-015-0477-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aerobic vaginitis (AV) is a vaginal infectious condition which is often confused with bacterial vaginosis (BV) or with the intermediate microflora as diagnosed by Nugent's method to detect BV on Gram-stained specimens. However, although both conditions reflect a state of lactobacillary disruption in the vagina, leading to an increase in pH, BV and AV differ profoundly. While BV is a noninflammatory condition composed of a multiplex array of different anaerobic bacteria in high quantities, AV is rather sparely populated by one or two enteric commensal flora bacteria, like Streptococcus agalactiae, Staphylocuccus aureus, or Escherichia coli. AV is typically marked by either an increased inflammatory response or by prominent signs of epithelial atrophy or both. The latter condition, if severe, is also called desquamative inflammatory vaginitis. As AV is per exclusionem diagnosed by wet mount microscopy, it is a mistake to treat just vaginal culture results. Vaginal cultures only serve as follow-up data in clinical research projects and are at most used in clinical practice to confirm the diagnosis or exclude Candida infection. AV requires treatment based on microscopy findings and a combined local treatment with any of the following which may yield the best results: antibiotic (infectious component), steroids (inflammatory component), and/or estrogen (atrophy component). In cases with Candida present on microscopy or culture, antifungals must be tried first in order to see if other treatment is still needed. Vaginal rinsing with povidone iodine can provide rapid relief of symptoms but does not provide long-term reduction of bacterial loads. Local antibiotics most suitable are preferably non-absorbed and broad spectrum, especially those covering enteric gram-positive and gram-negative aerobes, like kanamycin. To achieve rapid and short-term improvement of severe symptoms, oral therapy with amoxyclav or moxifloxacin can be used, especially in deep dermal vulvitis and colpitis infections with group B streptococci or (methicillin resistant) Staphylococcus aureus. Since the latter colonizations are frequent, but seldom inflammatory infections, we in general discourage the use of oral antibiotics in women with AV. In cases with a severe atrophy component (more than 10 % of epithelial cells are of the parabasal type), local estrogens can be used; and in postmenopausal or breast cancer patients with a contraindication for estrogens, even a combination of probiotics with an ultra-low dose of local estriol may be considered.
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