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Donders GGG, Donders FHWV. New developments in the management of vulvovaginal atrophy: a comprehensive overview. Expert Opin Pharmacother 2023; 24:599-616. [PMID: 36951262 DOI: 10.1080/14656566.2023.2194017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
INTRODUCTION Proper recognition and individualized therapy of vulvovaginal atrophy (VVA) is paramount. AREAS COVERED Assessment of VVA should be done using several questionnaires in combination with wet mount microscopy to determine Vaginal Cell Maturation Index (VCMI) and infections. PubMed searches were done between 1march 2022 and 15 Oct 2022.Low dose vaginal estriol seems safe, efficient, and could be used in patients with contraindications for steroid hormones such as women with a history of breast cancer, and should therefore be considered as first choice hormonal treatment, when non-hormonal treatments fail. New estrogens, androgens and several Selective Estrogen Receptor Modulators (SERMs) are being developed and tested. Intravaginal Hyaluronic Acid (HA) or Vit D can help women who can't or don't want to use hormones. EXPERT OPINION Proper treatment is not possible without a correct and full diagnosis, including microscopy of the vaginal fluid. Low dose vaginal estrogen treatment, especially with estriol, is very efficient and is preferred in most women with VVA. Oral ospemifene and vaginal dihydroepiandrosterone (DHEA) are now considered efficient and safe alternative therapies for VVA. More safety data are waited for several SERMs and for a newly introduced estrogen: estretol (E4), although so far no major side effects were seen from these drugs. Indications for laser treatments are questionable.
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Affiliation(s)
- Gilbert G G Donders
- Femicare vzw, Tienen, Belgium
- Department of OB/Gyn Antwerp University, Belgium
- Department OB/Byn or Regional Hospital H. Hart Tienen, Belgium
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Lūse L, Urtāne AĶ, Lisovaja I, Jermakova I, Donders GGG, Vedmedovska N. Literature Review of Cervical Regeneration after Loop Electrosurgical Excision Procedure, and Study Project (CeVaLEP) Proposal. J Clin Med 2022; 11:jcm11082096. [PMID: 35456188 PMCID: PMC9030886 DOI: 10.3390/jcm11082096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Objective: To compile existing knowledge on the level of cervical regeneration (detected by ultrasound) after loop electrosurgical excision procedure (LEEP) and to suggest research protocol for further studies. Methods: We conducted a literature search of Medline, Web of Science, Scopus, and Cochrane databases using the keywords “cervix” and “regeneration” without year restrictions. Our eligibility criteria included studies that analysed cervical volume and length regeneration using ultrasound. A literature review was conducted following PRISMA guidelines and registered in PROSPERO (reg. no. CRD42021264062). Information about the studies was extracted from each analysed study on an Excel datasheet and the average regeneration with standard deviation was calculated. All included studies’ possible biases were assessed by the National Institutes of Health’s (NIH) quality assessment tool. Results: The literature search identified 802 papers and four trials (n = 309) that met our criteria. They investigated cervical length and volume regeneration after LEEP using ultrasound, concluding that there is a profound regeneration deficit. Average cervical length regeneration after 6 months was 83.4% (±10.8%) and volume regeneration was 87.4% (±6.1%). All analysed studies had their biases; therefore, based on the conducted studies’ protocols, we present a CeVaLEP research protocol to guide high-quality studies. Conclusion: After LEEP, there is a cervical regeneration deficit. There is a lack of high-quality studies that assess cervical volume regeneration and its relation to obstetrical outcomes. There is a gap in the field and more research is needed to define the prenatal risks related to cervical regeneration.
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Affiliation(s)
- Laura Lūse
- Faculty of Residency, Rīga Stradiņš University, LV-1007 Riga, Latvia;
- Correspondence:
| | - Anda Ķīvīte Urtāne
- Department of Public Health and Epidemiology, Rīga Stradiņš University, LV-1007 Riga, Latvia;
| | - Ija Lisovaja
- Faculty of Residency, Rīga Stradiņš University, LV-1007 Riga, Latvia;
| | - Irina Jermakova
- Gynecology Department, Riga Eastern Clinical University Hospital, LV-1079 Riga, Latvia;
| | - Gilbert G. G. Donders
- Department OB/Gyn, Antwerp University Hospital, 2650 Edegem, Belgium;
- Femicare VZW, Clinical Research for Women, 3300 Tienen, Belgium
| | - Natālija Vedmedovska
- Department of Obstetrics and Gynecology, Rīga Stradiņš University, LV-1007 Riga, Latvia;
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Donders GGG, Ruban K, Donders F, Reybrouck R. Lab-Based Retrospective 10-Year Analysis Shows Seasonal Variation of Vaginal Candida Infection Rates in Belgium. J Clin Med 2022; 11:jcm11030574. [PMID: 35160026 PMCID: PMC8836942 DOI: 10.3390/jcm11030574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 11/28/2022] Open
Abstract
Candida vulvovaginitis is a frequent condition, and although several risk factors are known, its behavior is still enigmatic. The seasonal influence of climate conditions and living habits on its prevalence was studied. In a retrospective lab-based cohort over 10 years, we studied the prevalence of Candida in 12,941 vaginal cultures taken from women attending a vulvovaginitis clinic. The prevalence of non-albicans and albicans species were compared per month to detect differences in positivity rates in summer versus winter months. Chi-square and chi-square for trend were used. Of the 2109 (16.3%) Candida spp. positive swabs, 201 (1.0%) revealed non-albicans species, varying between 1.0% and 2.0% per month, but without significant monthly differences. Over the 10 years, compared to other months, vaginal Candida was more frequent in June (19.0%, p = 0.008) and less frequent in December (14.5%, p = 0.04). The Candida prevalence was 15.5% in summer (June/July/August) versus 14.0% in the winter (Dec/Jan/Feb, p = 0.04). Change in temperature, dietary habits, and bodily adaptations due to increased amount of sunlight were discussed as potential pathophysiological mechanisms to explain the excess of Candida in summertime. Further confirmatory research would be beneficial. Women at risk for Candida vulvovaginitis should pay more attention to living habits in summertime to avoid recurrences.
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Affiliation(s)
- Gilbert G. G. Donders
- Femicare, Clinical Research for Women, 3300 Tienen, Belgium; (K.R.); (F.D.)
- Department of Obstetrics & Gynecology, Regional Hospital Heilig Hart, Kliniekstraat 45, 3300 Tienen, Belgium
- Department of Obstetrics and Gynecology, University Hospital Antwerpen, 2650 Edegem, Belgium
- Correspondence: ; Tel.: +32-16-808102 or +32-16-809011
| | - Kateryna Ruban
- Femicare, Clinical Research for Women, 3300 Tienen, Belgium; (K.R.); (F.D.)
| | - Francesca Donders
- Femicare, Clinical Research for Women, 3300 Tienen, Belgium; (K.R.); (F.D.)
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Donders GGG, Grinceviciene S, Haldre K, Lonnee-Hoffmann R, Donders F, Tsiakalos A, Adriaanse A, Martinez de Oliveira J, Ault K, Mendling W. ISIDOG Consensus Guidelines on COVID-19 Vaccination for Women before, during and after Pregnancy. J Clin Med 2021; 10:jcm10132902. [PMID: 34209801 PMCID: PMC8268868 DOI: 10.3390/jcm10132902] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction. Sars-CoV-2 infection poses particular problems in pregnancy, as the infection more frequently causes severe complications than in unaffected pregnant women or nonpregnant women with SARS-CoV-2 infection. Now that vaccination is available and rapidly being implemented worldwide, the question arises whether pregnant women should be vaccinated, and if so, whether they should receive priority. Methods. Available scientific data and available guidelines about vaccination against SARS-CoV-2 were collected by the Guideline Committee of the International Society of Infectious Diseases in Obstetrics and Gynecology (ISIDOG) and were analyzed, discussed and summarized as guidelines for healthcare workers caring for pregnant women. Concluding statements were graded according to the Oxford evidence-based medicine grading system. Results. There is evidence to consider pregnancy as a risk factor for serious complications of COVID-19 infection, even in the absence of additional risk factors, such as hypertension, diabetes and obesity which increase these risks even more in pregnancy. Currently available data slightly favor mRNA-based vaccines above vector-based vaccines during pregnancy and breastfeeding, until more safety data become available. Conclusion. ISIDOG advises policy makers and societies to prioritize pregnant women to receive vaccination against SARS-CoV-2 and favor the mRNA vaccines until further safety information becomes available.
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Affiliation(s)
- Gilbert G. G. Donders
- Femicare VZW Clinical Research for Women, 3300 Tienen, Belgium;
- Department Obstetrics and Gynecology, University Hospital Antwerp, 2650 Edegem, Belgium
- President International Society Infectious Diseases (ISIDOG), 3300 Tienen, Belgium
- Correspondence: ; Tel.: +32-16-80-81-02
| | - Svitrigaile Grinceviciene
- Department Biothemodynamics and Drug Design, Institute of Biotechnology and Life Sciences Center, Vilnius University, 01513 Vilnius, Lithuania;
| | - Kai Haldre
- East Tallin Central Hospital Women’s Clinic, 10138 Tallin, Estonia;
| | | | | | - Aristotelis Tsiakalos
- LETO-Obstetrician Gynecological & Surgical Center, Department Obstetrics and Gynecology, 11525 Athens, Greece;
| | - Albert Adriaanse
- Medisch Centrum Alkmaar, Department Obstetrics and Gynecology, 1814 Alkmaar, The Netherlands;
| | | | - Kevin Ault
- Department Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS 66160, USA;
| | - Werner Mendling
- German Center for Infections in Obstetrics and Gynceology, Department Obstetrics and Gynecology, 42283 Wupperthal, Germany;
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Plisko O, Zodzika J, Jermakova I, Pcolkina K, Prusakevica A, Liepniece-Karele I, Donders GGG, Rezeberga D. Aerobic Vaginitis-Underestimated Risk Factor for Cervical Intraepithelial Neoplasia. Diagnostics (Basel) 2021; 11:diagnostics11010097. [PMID: 33435407 PMCID: PMC7827831 DOI: 10.3390/diagnostics11010097] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 12/23/2020] [Accepted: 01/07/2021] [Indexed: 01/10/2023] Open
Abstract
The aim of this study is to analyse the association between vaginal microbiota and the histological finding of CIN. From July 2016 until June 2017, we included 110 consecutive patients with abnormal cervical cytology results referred for colposcopy to Riga East Clinical University Hospital Outpatient department in the study group. 118 women without cervical pathology were chosen as controls. Certified colposcopists performed interviews, gynaecological examinations and colposcopies for all participants. Material from the upper vaginal fornix was taken for pH measurement and wet-mount microscopy. Cervical biopsy samples were taken from all subjects in the study group and in case of a visual suspicion for CIN in the control group. Cervical pathology was more often associated with smoking (34.6% vs. 11.0%, p < 0.0001), low education level (47.2% vs. 25.5%, p = 0.001), increased vaginal pH (48.2% vs. 25.4%, p < 0.0001), abnormal vaginal microbiota (50% vs. 31.4%, p = 0.004) and moderate to severe aerobic vaginitis (msAV) (13.6% vs. 5.9%, p = 0.049) compared to controls. The most important independent risk factors associated with CIN2+ were smoking (OR 3.04 (95% CI 1.37–6.76), p = 0.006) and msAV (OR 3.18 (95% CI 1.13–8.93), p = 0.028). Bacterial vaginosis (BV) was found more often in CIN1 patients (8/31, 25.8%, p = 0.009) compared with healthy controls (8/118, 6.8%), or CIN2+ cases (8/79, 10.1%). In the current study msAV and smoking were the most significant factors in the development of CIN in HPV-infected women, especially high grade CIN. We suggest that AV changes are probably more important than the presence of BV in the pathogenesis of CIN and progression to cervix cancer and should not be ignored during the evaluation of the vaginal microbiota.
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Affiliation(s)
- Olga Plisko
- Department of Obstetrics and Gynecology, Riga Stradins University, LV-1007 Riga, Latvia; (J.Z.); (I.J.); (D.R.)
- Correspondence:
| | - Jana Zodzika
- Department of Obstetrics and Gynecology, Riga Stradins University, LV-1007 Riga, Latvia; (J.Z.); (I.J.); (D.R.)
- Gynecological Clinic, Riga East Clinical University Hospital, LV-1038 Riga, Latvia;
| | - Irina Jermakova
- Department of Obstetrics and Gynecology, Riga Stradins University, LV-1007 Riga, Latvia; (J.Z.); (I.J.); (D.R.)
- Gynecological Clinic, Riga East Clinical University Hospital, LV-1038 Riga, Latvia;
| | - Kristine Pcolkina
- Gynecological Clinic, Riga East Clinical University Hospital, LV-1038 Riga, Latvia;
| | | | | | - Gilbert G. G. Donders
- Femicare Clinical Research for Women, 3300 Tienen, Belgium;
- Department of Obstetrics and Gynecology, University of Antwerp, 2550 Antwerp-Edegem, Belgium
- Department of Obstetrics and Gynecology, Regional Hospital, 3300 Tienen, Belgium
| | - Dace Rezeberga
- Department of Obstetrics and Gynecology, Riga Stradins University, LV-1007 Riga, Latvia; (J.Z.); (I.J.); (D.R.)
- Gynecological Clinic, Riga East Clinical University Hospital, LV-1038 Riga, Latvia;
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Taghinezhad-S S, Keyvani H, Bermúdez-Humarán LG, Donders GGG, Fu X, Mohseni AH. Twenty years of research on HPV vaccines based on genetically modified lactic acid bacteria: an overview on the gut-vagina axis. Cell Mol Life Sci 2020; 78:1191-1206. [PMID: 32979054 PMCID: PMC7519697 DOI: 10.1007/s00018-020-03652-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 09/03/2020] [Accepted: 09/16/2020] [Indexed: 10/27/2022]
Abstract
Most cervical cancer (CxCa) are related to persistent infection with high-risk human papillomavirus (HR-HPV) in the cervical mucosa, suggesting that an induction of mucosal cell-mediated immunity against HR-HPV oncoproteins can be a promising strategy to fight HPV-associated CxCa. From this perspective, many pre-clinical and clinical trials have proved the potential of lactic acid bacteria (LAB) genetically modified to deliver recombinant antigens to induce mucosal, humoral and cellular immunity in the host. Altogether, the outcomes of these studies suggest that there are several key factors to consider that may offer guidance on improvement protein yield and improving immune response. Overall, these findings showed that oral LAB-based mucosal HPV vaccines expressing inducible surface-anchored antigens display a higher potential to induce particularly specific systemic and mucosal cytotoxic cellular immune responses. In this review, we describe all LAB-based HPV vaccine investigations by reviewing databases from international studies between 2000 and 2020. Our aim is to promote the therapeutic HPV vaccines knowledge and to complete the gaps in this field to empower scientists worldwide to make proper decisions regarding the best strategies for the development of therapeutic HPV vaccines.
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Affiliation(s)
- Sedigheh Taghinezhad-S
- Department of Microbiology, Faculty of Basic Sciences, Science and Research Branch, Islamic Azad University, Tehran, 1477893855, Iran
| | - Hossein Keyvani
- Department of Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, 1449614535, Iran
| | | | - Gilbert G G Donders
- Department of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium.,Femicare Clinical Research for Women, Tienen, Belgium
| | - Xiangsheng Fu
- Department of Gastroenterology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Amir Hossein Mohseni
- Department of Microbiology, Faculty of Basic Sciences, Science and Research Branch, Islamic Azad University, Tehran, 1477893855, Iran.
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Vedmedovska N, Bokucava D, Kivite-Urtane A, Rovite V, Zake-Nikitina L, Klovins J, Fodina V, Donders GGG. The Correlation Between Abnormal Uterine Artery Flow in the First Trimester and Genetic Thrombophilic Alteration: A Prospective Case-Controlled Pilot Study. Diagnostics (Basel) 2020; 10:diagnostics10090654. [PMID: 32878173 PMCID: PMC7555473 DOI: 10.3390/diagnostics10090654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/23/2020] [Accepted: 08/28/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Evaluation of the first trimester uterine artery flow can predict the development of obstetrical complications. A genotype, making women prone to microthrombi. constitutes the main known susceptibility factor for anomalous development of placenta. Our aim was to study whether polymorphisms of 10 genes leading to blood clotting abnormalities are related to abnormal uterine artery blood flow in the first trimester, and may predict placenta-related diseases. MATERIAL AND METHODS In primary analyses we included 19 singleton pregnancies with abnormal blood flow in the uterine arteries during the first trimester of gestation, and 24 matched control with normal flow patterns. All patients were genotyped for sequence variations in F5, F2, F11, MTHFR, SERPINE-1, CYP4V2, SELE, GP6, angiotensinogen (AGT) and fibrinogen gamma (FGG) genes and followed up until delivery. RESULTS There were no differences between groups regarding selected sequence variations in any of these genes. The co-occurrence of several polymorphisms in the same patient was also not related to the blood flow patterns in the uterine arteries. CONCLUSIONS Although we found certain trends of genetic polymorphisms being related to preeclampsia and fetal growth, we failed to find an association between clotting gene polymorphisms, single or in combination, with the abnormal uterine flow in the first trimester.
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Affiliation(s)
- Natalija Vedmedovska
- Department of Obstetrics and Gynecology, Riga Stradins University, LV-1007 Riga, Latvia;
- Correspondence: ; Tel.: +371-29429704
| | - Diana Bokucava
- Department of Obstetrics and Gynecology, Riga Stradins University, LV-1007 Riga, Latvia;
| | - Anda Kivite-Urtane
- Department of Public Health and Epidemiology, Riga Stradins University, LV-1010 Riga, Latvia;
| | - Vita Rovite
- Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia; (V.R.); (L.Z.-N.); (J.K.)
| | - Liene Zake-Nikitina
- Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia; (V.R.); (L.Z.-N.); (J.K.)
| | - Janis Klovins
- Latvian Biomedical Research and Study Centre, LV-1067 Riga, Latvia; (V.R.); (L.Z.-N.); (J.K.)
- Department of Medicine, University of Latvia, LV-1050 Riga, Latvia
| | | | - Gilbert G. G. Donders
- Department of Obstetrics and Gynecology, University of Antwerp, 2550 Antwerp-Edegem, Belgium;
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Donders F, Lonnée-Hoffmann R, Tsiakalos A, Mendling W, Martinez de Oliveira J, Judlin P, Xue F, Donders GGG. ISIDOG Recommendations Concerning COVID-19 and Pregnancy. Diagnostics (Basel) 2020; 10:E243. [PMID: 32338645 PMCID: PMC7235990 DOI: 10.3390/diagnostics10040243] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/16/2020] [Accepted: 04/18/2020] [Indexed: 12/15/2022] Open
Abstract
Providing guidelines to health care workers during a period of rapidly evolving viral pandemic infections is not an easy task, but it is extremely necessary in order to coordinate appropriate action so that all patients will get the best possible care given the circumstances they are in. With these International Society of Infectious Disease in Obstetrics and Gynecology (ISIDOG) guidelines we aim to provide detailed information on how to diagnose and manage pregnant women living in a pandemic of COVID-19. Pregnant women need to be considered as a high-risk population for COVID-19 infection, and if suspected or proven to be infected with the virus, they require special care in order to improve their survival rate and the well-being of their babies. Both protection of healthcare workers in such specific care situations and maximal protection of mother and child are envisioned.
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Affiliation(s)
| | | | - Aristotelis Tsiakalos
- Department Ob/Gyn, LETO Obstetrician Gynecological & Surgical Center, 11525 Athens, Greece;
| | - Werner Mendling
- German Center for Infections in Gynecology and Obstetrics, 42283 Wuppertal, Germany;
| | | | - Philippe Judlin
- Department OB/Gyn, CHU De Nancy—Université de Lorraine, 54000 Nancy, France;
| | - Fengxia Xue
- Department OB/Gyn, Tianjin Medical University General Hospital, Tianjin 30000, China;
| | - Gilbert G. G. Donders
- Femicare VZW Clinical Research for Women, 3300 Tienen, Belgium;
- Department Ob/Gyn, University Hospital Antwerp, 2650 Ekeren, Belgium
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Chavoustie SE, Carter BA, Waldbaum AS, Donders GGG, Peters KH, Schwebke JR, Paull JRA, Price CF, Castellarnau A, McCloud P, Kinghorn GR. Two phase 3, double-blind, placebo-controlled studies of the efficacy and safety of Astodrimer 1% Gel for the treatment of bacterial vaginosis. Eur J Obstet Gynecol Reprod Biol 2019; 245:13-18. [PMID: 31812702 DOI: 10.1016/j.ejogrb.2019.11.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Astodrimer is a dendrimer formulated in a vaginal gel to treat bacterial vaginosis (BV) and prevent recurrence. The objective of these studies was to confirm the efficacy and safety of Astodrimer 1 % Gel for treatment of BV. STUDY DESIGN Women with bacterial vaginosis were randomized 1:1 to Astodrimer 1 % Gel (Study 1 conducted in the United States, N = 127; Study 2 conducted in the United States, Germany and Belgium, N = 128) or placebo gel (Study 1, N = 123; Study 2, N = 123) at a dose of 5 g vaginally once daily for 7 days. The primary endpoint was clinical cure, defined as i) absence of bacterial vaginosis vaginal discharge; ii) <20 % clue cells; and iii) negative whiff test at day 9-12. Secondary efficacy analyses included clinical cure at day 21-30. Other endpoints at days 9-12 and 21-30 included Nugent cure (Nugent score ≤3), absence of symptoms, and adverse events. The primary analysis in the modified intent-to-treat population used the Cochran Mantel Haenszel test stratified by analysis center with a two-sided significance level of α = .05. RESULTS Astodrimer 1 % Gel was superior to placebo for the primary and selected secondary efficacy measures. Clinical cure rates at day 9-12 were 50.4 % (59/117) vs 16.5 % (19/115, P < .001) (Study 1) and 56.7 % (68/120) vs 21.4 % (25/117, P < .001) (Study 2) for astodrimer vs placebo. At day 21-30, clinical cure results showed a similar trend but the difference to placebo was not statistically significant. Nugent cure rates at day 9-12 were 12.8 % (15/117) vs 2.6 % (3/115, P = .004) (Study 1) and 13.3 % (16/120) vs 5.1 % (6/117, P = .030) (Study 2) for astodrimer vs placebo. A greater proportion of women receiving astodrimer reported absence of vaginal discharge and absence of vaginal odor at day 9-12 and day 21-30 compared with placebo. Adverse events were generally mild and self-limiting. For the combined studies, adverse events potentially related to treatment occurred in 14.7 % (37/252) of astodrimer patients vs 9.4 % (23/244) for placebo, including vulvovaginal candidiasis reported for 2.4 % (6/252) of astodrimer patients. CONCLUSION These results support a role for Astodrimer 1 % Gel as an effective, safe and well-tolerated treatment for women with bacterial vaginosis.
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Affiliation(s)
| | | | | | - Gilbert G G Donders
- Femicare Clinical Research for Women, Tienen, Department of Obstetrics and Gynecology, The Regional Hospital Heilig Hart, Tienen, and University Hospital Antwerp, Antwerp, Belgium
| | | | - Jane R Schwebke
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, United States
| | | | | | | | | | - George R Kinghorn
- Royal Hallamshire and Sheffield Teaching Hospitals, Sheffield, United Kingdom
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Donders GGG, Ruban K, Depuydt C, Bellen G, Vanden Broeck D, Jonckheere J, Jacquemyn Y. Treatment Attitudes for Belgian Women With Persistent Trichomonas vaginalis Infection in the VlaResT Study. Clin Infect Dis 2019; 68:1575-1580. [PMID: 30395193 DOI: 10.1093/cid/ciy736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 09/26/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Because of its increasing prevalence worldwide, its sexual transmissibility and its facilitation of human immunodeficiency virus transmission, Trichomonas vaginalis (TV) infection constitutes an important public health concern. THE AIM OF THE STUDY While searching for possible resistant TV cases, adequacy of management of TV-infected women was assessed. METHODS Cervical cytology between July 2007 and July 2014 was tested with TV polymerase chain reaction, and 304 women expressed repeatedly positive results, 718 in total. For each of these positive results, a questionnaire about treatment decisions was sent to the 182 Belgian physicians treating these women. RESULTS From the 346 returned questionnaires by their physician it was evident that 58.1% of women with repeatedly positive TV had received no treatment. TV was overlooked in 31.5%, and in 17.6% the test result was seen but ignored. Upon seeing the positive result, 23.9% of physicians decided that this finding was not important enough to institute treatment, and/or requested confirmatory tests. Adequate treatment was prescribed in 38.4%. Retreatment after failed therapy was given in only 29.3% of the cases. And 60% of the partners of women with persistent TV infection were not traced, nor treated. CONCLUSION Most of the repeatedly positive TV infection may not be due to antibiotics resistance. The low awareness, poor attention, failure of contact tracing, and low rates of proper treatment provided by treating physicians question the adequacy of the current management of TV infection and requires renewed education campaigns and increased surveillance.
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Affiliation(s)
| | | | | | | | | | - Jef Jonckheere
- Algemeen Medisch Laboratorium (AML), Sonic Healthcare, Antwerp, Belgium
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Allonsius CN, Vandenheuvel D, Oerlemans EFM, Petrova MI, Donders GGG, Cos P, Delputte P, Lebeer S. Inhibition of Candida albicans morphogenesis by chitinase from Lactobacillus rhamnosus GG. Sci Rep 2019; 9:2900. [PMID: 30814593 PMCID: PMC6393446 DOI: 10.1038/s41598-019-39625-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/24/2019] [Indexed: 01/09/2023] Open
Abstract
Lactobacilli have been evaluated as probiotics against Candida infections in several clinical trials, but with variable results. Predicting and understanding the clinical efficacy of Lactobacillus strains is hampered by an overall lack of insights into their modes of action. In this study, we aimed to unravel molecular mechanisms underlying the inhibitory effects of lactobacilli on hyphal morphogenesis, which is a crucial step in C. albicans virulence. Based on a screening of different Lactobacillus strains, we found that the closely related taxa L. rhamnosus, L. casei and L. paracasei showed stronger activity against Candida hyphae formation compared to other Lactobacillus species tested. By exploring the activity of purified compounds and mutants of the model strain L. rhamnosus GG, the major peptidoglycan hydrolase Msp1, conserved in the three closely related taxa, was identified as a key effector molecule. We could show that this activity of Msp1 was due to its ability to break down chitin, the main polymer in the hyphal cell wall of C. albicans. This identification of a Lactobacillus-specific protein with chitinase activity having anti-hyphal activity will assist in better strain selection and improved application in future clinical trials for Lactobacillus-based Candida-management strategies.
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Affiliation(s)
- Camille Nina Allonsius
- University of Antwerp, Department of Bioscience Engineering, Research Group Environmental Ecology and Applied Microbiology, Antwerp, Belgium
| | - Dieter Vandenheuvel
- University of Antwerp, Department of Bioscience Engineering, Research Group Environmental Ecology and Applied Microbiology, Antwerp, Belgium
| | - Eline F M Oerlemans
- University of Antwerp, Department of Bioscience Engineering, Research Group Environmental Ecology and Applied Microbiology, Antwerp, Belgium
| | - Mariya I Petrova
- University of Antwerp, Department of Bioscience Engineering, Research Group Environmental Ecology and Applied Microbiology, Antwerp, Belgium
| | - Gilbert G G Donders
- Department of Obstetrics and Gynaecology, Antwerp University Hospital, Antwerp, Belgium.,Femicare Clinical Research for Women, Tienen, Belgium
| | - Paul Cos
- University of Antwerp, Department of Biomedical Sciences, Laboratory of Microbiology, Parasitology and Hygiene, Wilrijk, Belgium
| | - Peter Delputte
- University of Antwerp, Department of Biomedical Sciences, Laboratory of Microbiology, Parasitology and Hygiene, Wilrijk, Belgium
| | - Sarah Lebeer
- University of Antwerp, Department of Bioscience Engineering, Research Group Environmental Ecology and Applied Microbiology, Antwerp, Belgium.
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Donders GGG, Viera Baptista P. The ReCiDiF method to treat recurrent vulvovaginal candidosis: A friend with benefits. Aust N Z J Obstet Gynaecol 2019; 58:E5. [PMID: 29864220 DOI: 10.1111/ajo.12795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Gilbert G G Donders
- Femicare, Tienen, Belgium.,Department of Obstetrics and Gynecology, University Hospital Antwerp, Antwerp, Belgium
| | - Pedro Viera Baptista
- Department of Gynecology and Obstetrics, Centro Hospitalar de São João, Porto, Portugal
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13
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Depuydt* CE, Donders GGG, Verstraete L, Vanden Broeck D, Beert JFA, Salembier G, Bosmans E, DhontT N, Van Der Auwera I, Vandenborne K, Ombelet W. Time has come to include Human Papillomavirus (HPV) testing in sperm donor banks. Facts Views Vis Obgyn 2018; 10:201-205. [PMID: 31367292 PMCID: PMC6658204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
HPV is well known as a potential cause of cervical cancer. Less well known is its link to temporal subfertility that is caused by binding of infectious virions to the spermatozoa's head which induces sperm-DNA damage and causes a reduction in clinical pregnancy rates in women receiving HPV positive semen. This impact on the global fertility burden remains greatly underestimated and underexplored. This risk of reduced fertility due to infectious HPV in sperm is especially important when donor sperm insemination is considered, since testing for the presence of HPV virions before use seems warranted. We tested 514 donor sperm samples from 3 different sperm banks for 18 different HPV types. Overall 3.9% (20/514) of tested donor sperm was positive for HPV, with different prevalence among the 3 different sperm banks (3.6% bank A, 3.1% bank B and 16.7% bank C). Also the HPV virion per spermatozoon ratio in donor samples was similar across the different sperm banks (95% CI 0,01 to 1,07 HPV virions/spermatozoon). When HPV positive donor sperm was used, no clinical pregnancies resulted, whereas when HPV negative donor sperm was used the clinical pregnancy rate was 14.6%. From both a cost/benefit and a safety point of view we recommend that donor sperm should always be tested for HPV before using it for insemination.
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Affiliation(s)
- CE Depuydt*
- Department of Hormonology and Reproductive Health, AML, Sonic Healthcare, Antwerp, Belgium;,Intermediate structure for human body material, AML, Sonic Healthcare, Antwerp, Belgium
| | - GGG Donders
- Femicare, Clinical Research for Women, Tienen, Belgium;,Department of Obstetrics and Gynecology, Regional Hospital Heilig Hart, Tienen, Belgium;,University Hospital Antwerpen, Antwerp, Belgium
| | - L Verstraete
- Department of Hormonology and Reproductive Health, AML, Sonic Healthcare, Antwerp, Belgium;,Intermediate structure for human body material, AML, Sonic Healthcare, Antwerp, Belgium
| | - D Vanden Broeck
- Department of Clinical and Molecular Pathology, AML, Sonic Healthcare, Antwerp, Belgium; 7,National Reference Centre for HPV, Brussels, Belgium;,Department of Obstetrics and Gynecology, International Centre for Reproductive Health, Ghent University, Ghent
| | - JFA Beert
- Department of Hormonology and Reproductive Health, AML, Sonic Healthcare, Antwerp, Belgium;,Intermediate structure for human body material, AML, Sonic Healthcare, Antwerp, Belgium;,Department of Clinical and Molecular Pathology, AML, Sonic Healthcare, Antwerp, Belgium; 7
| | - G Salembier
- Department of Clinical and Molecular Pathology, AML, Sonic Healthcare, Antwerp, Belgium; 7
| | - E Bosmans
- Department of Hormonology and Reproductive Health, AML, Sonic Healthcare, Antwerp, Belgium;,Intermediate structure for human body material, AML, Sonic Healthcare, Antwerp, Belgium
| | - N DhontT
- Genk Institute for Fertility Technology, ZOL Hospitals, Genk, Belgium
| | - I Van Der Auwera
- Genk Institute for Fertility Technology, ZOL Hospitals, Genk, Belgium
| | - K Vandenborne
- Genk Institute for Fertility Technology, ZOL Hospitals, Genk, Belgium
| | - W Ombelet
- Genk Institute for Fertility Technology, ZOL Hospitals, Genk, Belgium;,UHasselt, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
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14
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Grinceviciene S, Ruban K, Bellen G, Donders GGG. Sexual behaviour and extra-genital colonisation in women treated for recurrent Candida vulvo-vaginitis. Mycoses 2018; 61:857-860. [PMID: 29998617 DOI: 10.1111/myc.12825] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study analyses a relation between sexual habits and the presence of Candida in extra-genital locations as well as a potential effect on therapy response. MATERIAL AND METHODS Candida cultures were obtained from mouth, nose, anus, urine and perineum of 117 women enrolled in a RVVC treatment trial (ReCiDiF). Sexual behaviour and carriage rates of extra-genital Candida of women responding well to treatment were compared to that of non-responders. RESULTS Most respondents were heterosexual. All but one practiced vaginal sex. Regular receptive oral sex was not related to multiple site colonisation with Candida (OR = 1.27; CI95% 0.36-4.48), nor to non-response to therapy (OR = 1.3; CI 95% 0.41-4.73). Also, masturbation was not related to response to therapy (OR 0.8; CI95% 0.31-1.84), nor was anal sex (OR = 0.54; CI95% 0.11-2.72). CONCLUSION Neither oral nor casual anal sex, nor masturbation can be held responsible for the association of the multiple site/anal colonisation with Candida and inferior response to fluconazole maintenance therapy. Changing sexual behaviour during fluconazole maintenance treatment for RVVC in otherwise healthy women should not be advocated. Also, treatment of asymptomatic sexual partners of women with RVVC is not recommended.
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Affiliation(s)
- Svitrigaile Grinceviciene
- Femicare vzw, Tienen, Belgium.,Institute of Biotechnology Department of Biothermodynamics and Drug Design, Vilnius University, Vilnius, Lithuania
| | | | | | - Gilbert G G Donders
- Femicare vzw, Tienen, Belgium.,Department of OB/Gyn, Antwerp University, Antwerp, Belgium
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15
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Balla E, Donders GGG. Features of syphilis seropositive pregnant women raising alarms in Hungary, 2013-2016. Eur J Obstet Gynecol Reprod Biol 2018; 228:274-278. [PMID: 30053759 DOI: 10.1016/j.ejogrb.2018.07.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The incidence of syphilis has been on the rise in Hungary over the last decades. We aimed to assess the syphilis seroprevalence in pregnant women during 2013-2016. The secondary aims were to describe seropositivity by age and gestational age, to estimate infectivity rates in different age groups, and to compare the efficacy of mandatory prenatal screening versus individual venereological testing in revealing syphilis. STUDY DESIGN During the above mentioned period the reactive serum samples (N = 527) of 49,965 pregnant women undergoing routine screening were submitted for syphilis verification to the Bacterial STI Reference Laboratory, National Center for Epidemiology, Budapest, Hungary. The confirmation process included titrated RPR and TPHA tests performed simultaneously. The tested women were considered seronegative if both tests gave negative results. When any of these tests proved indeterminate or positive, anti-Treponema pallidum IgG and IgM ELISA tests were performed. Patients confirmed for the presence for specific IgG were judged seropositive. Further evaluation of potential infectivity of seropositive patients was carried out on RPR reactivity. RESULTS Syphilis seropositivity was detected in overall 2.9‰ (N = 148) of the cases. RPR-negative cases, i.e. past infections were confirmed in 36% (53/148); weak-reactive RPR (titres≤8) cases, i. e. past/early acute infections in 37% (55/148); strong-reactive RPR (titres>8) cases suggesting recent syphilis in 27% (40/148). Half of the infectious syphilis cases (20/40) belonged to the 15-24 age group. The gestational age at screening was available of 123 seropositive women, out of whom 27 (22%) were diagnosed late, in the third trimester. Nineteen (13%) out of all seropositives were detected via individual venereological testing before/instead of general prenatal screening. CONCLUSIONS The majority of infected pregnants may remain undetected due to the lack of mandatory general prenatal screening. The seropositivity for syphilis in pregnancy of 2.9/1000, of which one quarter were recent and infectious, the late diagnosis of syphilis in one in five, and the low pick-up rate of individualised instead of generalized screening are alarming signals and call for more effective prevention strategies, focusing on the most vulnerable adolescents, as well as on the first trimester of pregnancy.
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Affiliation(s)
- Eszter Balla
- Department of Bacteriology II., National Public Health Institute (former National Center for Epidemiology), Budapest, Hungary.
| | - Gilbert G G Donders
- Femicare Clinical Research for Women, Tienen, Belgium; Department of Obstetrics and Gynaecology, University Hospital Antwerp, Edegem, Belgium
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16
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Donders GGG, Bellen G, Ruban KS. Abnormal vaginal microbioma is associated with severity of localized provoked vulvodynia. Role of aerobic vaginitis and Candida in the pathogenesis of vulvodynia. Eur J Clin Microbiol Infect Dis 2018; 37:1679-1685. [DOI: 10.1007/s10096-018-3299-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 06/05/2018] [Indexed: 10/28/2022]
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17
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Donders GGG, Grinceviciene S, Bellen G, Jaeger M, Ten Oever J, Netea MG. Is non-response to fluconazole maintenance therapy for recurrent Candida vaginitis related to sensitization to atopic reactions? Am J Reprod Immunol 2018; 79:e12811. [PMID: 29469170 DOI: 10.1111/aji.12811] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/11/2017] [Indexed: 12/14/2022] Open
Abstract
PROBLEM Is sensitization to atopic reaction related to treatment response of recurrent Candida vulvovaginal (RVVC)? METHOD OF THE STUDY Analysis of ReCiDiF trial data of optimal (OR) and non-responders (NR) to fluconazole maintenance treatment, to explore medical history, physical status, family history, and vaginal immune response for potential sensitization to atopic reaction. RESULTS Sociodemographic characteristics of 33 NR women were not different from 38 OR. NR had received higher number of different treatments (mean difference 1.6 different treatments (95% CI: 0.20-2.97), P = .03) and had more episodes of disease (P < .05). Multivariate regression analysis showed that family history of atopy (OR: 4.9, CI 95%: 1.1-22.2), duration of symptoms (OR: 1.2, CI 95%: 1.02-1.5), and vulvar excoriation (OR: 3.6, CI 95%: 1.4-9.3) were related to non-response. Vulvar excoriation at entry was the only statistically significant predictive factor for non-response in multivariate analysis with specificity 77.8% and sensitivity 51.6%. CONCLUSION Women with RVVC with vulvar excoriation, longer duration of disease, and family history of atopic disease are at increased risk not to respond to maintenance fluconazole treatment.
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Affiliation(s)
- Gilbert G G Donders
- Femicare vzw, Tienen, Belgium.,Department of OB/Gyn, Antwerp University, Antwerp, Belgium
| | - Svitrigaile Grinceviciene
- Femicare vzw, Tienen, Belgium.,Institute of Biotechnology, Department of Biothermodynamics and Drug Design, Vilnius University, Vilnius, Lithuania
| | | | - Martin Jaeger
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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18
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Donders GGG, Ravel J, Vitali B, Netea MG, Salumets A, Unemo M. Role of Molecular Biology in Diagnosis and Characterization of Vulvo-Vaginitis in Clinical Practice. Gynecol Obstet Invest 2017; 82:607-616. [PMID: 29017160 DOI: 10.1159/000478982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 06/24/2017] [Indexed: 11/19/2022]
Abstract
The diagnosis of vulvo-vaginal complaints has always been enigmatic in obstetrics and gynecology. Patients with clear, pathognomonic symptoms end up with a proper diagnosis and treatment most of the time, but unfortunately we are now living in a world where women reach out to the Internet and readily get all information as to which disease their symptoms correspond to and also find the appropriate treatment "over-the-counter." Because of this trend, we as specialists are increasingly confronted with patients with complex and combined conditions. At the same time, extremely sensitive and accurate diagnostic tools are now being developed at a rapid pace, allowing the physicians to diagnose vulvo-vaginal disease with a substantially increased precision. Moreover, many of these molecular biology (MB)-based tests have become so common and affordable that self-sampling and self-testing are no longer utopia. On the other hand, too much information that is too readily available and that is too affordable also encompasses pitfalls, leading to gross overtreatment and psychological burden. As experienced caregivers, we should supervise these evolutions, define their place and proper use as diagnostic tools, utilize their potential as ad hoc tools to follow-up treatment efficacy and guide how such tools can be used for responsible self-testing. In the present paper, responding to the need for appropriate, quality assured and accessible tests for vulvo-vaginitis and the huge potential delivered by the rapidly developing MB methods, we recommend the need for a broad and regular discussion forum, composed of both clinical and technical experts and opinion makers, in order to match the needs with the huge opportunities and ideally combine the initiatives and forces into the same direction. This forum should then translate conceived strategies into regularly updated, evidence-based national and international guidelines.
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19
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Balla E, Donders GGG, Petrovay F, Urbán E. Seroprevalence of anti- Chlamydia trachomatis IgM in neonatal respiratory tract infections in Hungary. J Med Microbiol 2017; 66:1114-1117. [PMID: 28771138 DOI: 10.1099/jmm.0.000557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose. To determine the seroprevalence of specific IgM indicative of respiratory tract infection (RTI) due to Chlamydia trachomatis (CT) among symptomatic infants.Methodology. A descriptive study was conducted on young infants up to 5 months old at the Bacterial Sexually Transmitted Infections Reference Laboratory, National Centre for Epidemiology, Budapest, covering the period 2008-2016. Serum samples from infants suffering from RTIs were screened with a micro-immunofluorescence test (Focus, Cypress, USA) for the presence of anti-Chlamydia trachomatis-specific IgM. A parallel Bordetella pertussis screening was performed by an indirect immunofluorescence test (Euroimmun, Lübeck, Germany) that detected specific IgM.Results.The CT-specific serum IgM was highly reactive in 50 (19.1 %) of the 262 neonates with RTIs, while all proved negative for Bordetella pertussis-specific IgM.Conclusion. Vertically transmitted C. trachomatis must be regarded as a common pathogen among symptomatic neonates with RTIs in Hungary. Routine screening and treatment of pregnant women could be one option to help prevent these conditions. Focused laboratory testing based on raised clinical awareness should enable early diagnosis and appropriate therapy for symptomatic infants.
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Affiliation(s)
- Eszter Balla
- Department of Bacteriology II., National Public Health Institute, Budapest, Hungary
| | - Gilbert G G Donders
- Femicare Clinical Research for Women, Tienen, Belgium.,Department of Obstetrics and Gynecology, University Hospital Antwerp, Edegem, Belgium
| | - Fruzsina Petrovay
- Department of Bacteriology II., National Public Health Institute, Budapest, Hungary
| | - Edit Urbán
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
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20
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Donders GGG, Ruban K, Bellen G, Petricevic L. Mycoplasma/Ureaplasma infection in pregnancy: to screen or not to screen. J Perinat Med 2017; 45:505-515. [PMID: 28099135 DOI: 10.1515/jpm-2016-0111] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/01/2016] [Indexed: 11/15/2022]
Abstract
Mycoplasmata have been linked to pregnancy complications and neonatal risk. While formerly a limited number of species could be discovered by cultures, molecular biology nowadays discovers both lower quantities and more diverse species, making us realize that mycoplasmata are ubiquitous in the vaginal milieu and do not always pose a danger for pregnant women. As the meaning of mycoplasmata in pregnancy is not clear to many clinicians, we summarized the current knowledge about the meaning of different kinds of mycoplasmata in pregnancy and discuss the potential benefits and disadvantages of treatment. Currently, there is no general rule to screen and treat for mycoplasmata in pregnancy. New techniques seem to indicate that Ureaplasma parvum (Up), which now can be distinguished from U. urealyticum (Uu), may pose an increased risk for preterm birth and bronchopulmonary disease in the preterm neonate. Mycoplasma hominis (Mh) is related to early miscarriages and midtrimester abortions, especially in the presence of abnormal vaginal flora. Mycoplasma genitalium (Mg) is now recognized as a sexually transmitted infection (STI) that is involved in the causation of cervicitis, pelvic inflammatory disease (PID) in non-pregnant, and preterm birth and miscarriages in pregnant women, irrespective of the presence of concurrent other STIs, like Chlamydia or gonorrhoea. Proper studies to test for efficacy and improved pregnancy outcome are scarce and inconclusive. Azythromycin is the standard treatment now, although, for Mg, this may not be sufficient. The role of clarithromycin in clinical practice still has to be established. There is a stringent need for new studies based on molecular diagnostic techniques and randomized treatment protocols with promising and safe antimicrobials.
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21
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Balla E, Petrovay F, Erdősi T, Balázs A, Henczkó J, Urbán E, Donders GGG. Distribution of Chlamydia trachomatis genotypes in neonatal conjunctivitis in Hungary. J Med Microbiol 2017; 66:915-918. [DOI: 10.1099/jmm.0.000523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Eszter Balla
- Department of Bacteriology II, National Public Health Institute, Budapest, Hungary
| | - Fruzsina Petrovay
- Department of Bacteriology II, National Public Health Institute, Budapest, Hungary
| | - Tímea Erdősi
- Department of Phage and Molecular Typing, National Public Health Institute, Budapest, Hungary
| | - Andrea Balázs
- Department of Bacteriology II, National Public Health Institute, Budapest, Hungary
| | - Judit Henczkó
- Department of Bacteriology II, National Public Health Institute, Budapest, Hungary
| | - Edit Urbán
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Gilbert G. G. Donders
- Femicare Clinical Research for Women, Tienen, Belgium
- Department of Obstetrics and Gynecology, University Hospital Antwerp, Edegem, Belgium
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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: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Donders GGG, Sobel JD. Candida vulvovaginitis: A store with a buttery and a show window. Mycoses 2016; 60:70-72. [PMID: 27687503 DOI: 10.1111/myc.12572] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 08/31/2016] [Accepted: 09/07/2016] [Indexed: 11/29/2022]
Abstract
Although being an utterly frequent, non-mortal, yet distressing disease, and despite good knowledge of the pathogenesis and the availability of specific and safe treatment, vulvovaginal Candida (VVC) infection remains one of the most enigmatic problems for both physicians and patients. Good treatment requires a proper diagnosis. Too many caregivers (and patients treating themselves) react too simple-minded on the symptoms of VVC and treat VVC where they see it on the vulva. In this opinion paper, we plea for a thorough examination of women with VVC, especially in those women who suffer from recurrent disease since a long time, sometimes decades, which necessitates intensive examination of the vaginal flora, as this is invariably the reservoir for relapses and recurrent vulvitis. Examination of such complicated cases requires experienced clinical judgement, expertise bedside phase contrast microscopy of fresh vaginal fluid, classical cultures on Sabouroud medium and, if still unresolved, repetitive cultures taken by the patient herself at moments of symptoms, and/or nuclear acid amplification techniques to detect Candida genes in the vaginal fluid. Even if only vulvitis is evident, thorough expert examination of vaginal fluid is obligatory to diagnose VVC.
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Affiliation(s)
- Gilbert G G Donders
- Femicare Clinical Research for Women, Tienen, Belgium.,Department of OB/Gyn, University Hospital Antwerp, Edegem, Belgium
| | - Jack D Sobel
- Department of Infectious Diseases, Wayne State University, Detroit, MI, USA
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Donders GGG, Vieira-Baptista P. Bacterial vaginosis and inflammatory response showed association with severity of cervical neoplasia in HPV-positive women. Diagn Cytopathol 2016; 45:472-473. [DOI: 10.1002/dc.23453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/26/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Gilbert G. G. Donders
- Femicare VZW Clinical Research for Women; Tienen Belgium
- Department of Obstetrics and Gynecology; Regional Hospital H Hart Tienen; Belgium
- Department of Obstetrics and Gynecology; University Hospital Antwerp; Belgium
| | - Pedro Vieira-Baptista
- Department of Obstetrics and Gynecology; Centro Hospitalar De São João; Porto Portugal
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Donders GGG, Donders F, Bellen G, Depuydt C, Eggermont N, Michiels T, Lule J, Byamughisa J. Screening for abnormal vaginal microflora by self-assessed vaginal pH does not enable detection of sexually transmitted infections in Ugandan women. Diagn Microbiol Infect Dis 2015; 85:227-30. [PMID: 27112831 DOI: 10.1016/j.diagmicrobio.2015.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 12/06/2015] [Accepted: 12/22/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Is self-assessed vaginal pH measurement to detect abnormal vaginal bacterial microflora (AVF) an adequate prescreening method for detection of genital sexually transmitted infections (STIs)? MATERIALS AND METHODS A total of 360 Ugandan women tested themselves with a gloved finger and a pH color strip. PCR for bacterial vaginosis (BV)-associated bacteria was tested by PCR for Mycoplasma hominis, Ureaplasma urealyticum, and/or Atopobium vaginae, while the STIs were diagnosed by positive PCR for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and/or Trichomonas vaginalis. RESULTS A strong correlation was found between self-assessed pH values and BV-associated bacteria (P<0.0001), but not with STIs, not as single infections, nor in general. CONCLUSION Self-measured vaginal pH correlated well with markers of high-risk microflora types such as BV or aerobic vaginitis, but not with STIs. Hence, in a screening program addressing AVF in low-resource countries, extra specific tests are required to exclude STIs.
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Affiliation(s)
- Gilbert G G Donders
- Femicare vzw, Clinical Research for Women, Tienen, Belgium; Department of Obstetrics and Gynaecology, University Hospital Antwerpen, Antwerp, Belgium; Department of Obstetrics and Gynaecology, General Hospital H Hart, Tienen, Belgium.
| | | | - Gert Bellen
- Femicare vzw, Clinical Research for Women, Tienen, Belgium.
| | - Christophe Depuydt
- Department of Molecular Diagnostics, Algemeen Medisch Laboratorium (AML), Sonic HealthCare Benelux, Antwerp, Belgium.
| | | | | | - John Lule
- Department Obstetrics and Gynaecology, Mulago University Hospital, Kampala, Uganda.
| | - Jacobat Byamughisa
- Department Obstetrics and Gynaecology, Mulago University Hospital, Kampala, Uganda.
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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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Affiliation(s)
- G G G Donders
- Femicare Clinical Research for Women, Tienen; Department of Ob/Gyn, University Hospital Antwerp, Antwerp; Department of Ob/Gyn H Hart Hospital Tienen, Belgium
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Donders GGG, Bellen G. Assessing severity of pain in women with focal provoked vulvodynia: are von Frey filaments suitable devices? J Reprod Med 2014; 59:134-138. [PMID: 24724221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine whether von Frey filaments are effective in the standardized assessment of the severity of focal provoked vulvodynia (FPV) syndrome. STUDY DESIGN The data of 30 women with FPV attending monthly at our vulvovaginal disease clinic, for a collective total of 141 visits over 6 months, were analyzed. At each visit sensitivity tests at the vulvar vestibule were performed at the 5 and 7 o'clock area, totaling 282 measurements. A questionnaire, blinded to the examining physician, and a visual analogue score (VAS) of pain ranging from 1 (no pain) to 10 (maximal pain) was obtained of the discomfort felt when attempting sexual intercourse. RESULTS The VAS, the investigator assessment of redness, and the 1 to 10 score result of the cotton swab touch test at 5 and 7 o'clock were superior diagnostic tools for assessing the severity of the pain when compared to the use of von Frey filaments. CONCLUSION Although elegant because of the promise of objective, semiquantitative measurements, von Frey filaments are less suitable devices to assess severity of disease and response to treatment than are cotton swab 1 to 10 pain scores and clinical parameters like subjective pain (VAS) and objective focal redness.
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Abstract
INTRODUCTION The disturbing, foul-smelling discharge of bacterial vaginosis (BV) is a nuisance to women. Treatment possibilities for BV are limited and only achieve complete cure in 65 to 85% of cases. In most women, the condition relapses within weeks to months after treatment. AREAS COVERED In search of new therapeutic actions to cure, prevent or delay recurrences of BV, PubMed and web of science were searched for papers with i) decent study layout, ii) proper statistics, iii) comparison group (placebo or standard treatment) and iv) language English, French, Dutch or German. The following keywords were used: bacterial vaginosis and treatment or management or therapy or prophylaxis or prevention. Results were grouped in treatment categories and were discussed. EXPERT OPINION Clindamycin and metronidazole are the standard drugs for BV. As other antibiotic and acidifying treatments are progressively being studied, like tinidazole, rifaximin, nitrofuran, dequalinium chloride, vitamin C and lactic acid, more options have become available for switching therapy, combining therapies and long-term prophylactic use to prevent recurrences. Further studies are needed. Also, adjuvant therapy with probiotics may have a significant role in improving efficacy and in preventing recurrences. However, it is unlikely that probiotics will replace antibiotherapy.
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Affiliation(s)
- Gilbert G G Donders
- Femicare, Clinical Research center for Women, Tienen and Departments of Obstetrics and Gynaecology , Tienen , Belgium
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Donders GGG, Depuydt CE, Bogers JP, Vereecken AJ. Association of Trichomonas vaginalis and cytological abnormalities of the cervix in low risk women. PLoS One 2013; 8:e86266. [PMID: 24386492 PMCID: PMC3875579 DOI: 10.1371/journal.pone.0086266] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 12/12/2013] [Indexed: 11/18/2022] Open
Abstract
Objective Is Trichomonas vaginalis (TV) an inducing factor for the development of (pre-)cancerous lesions of the cervix? Design Cross sectional study. Setting Screening healthy Belgian women with low infection risk. Sample 63,251 consecutive liquid based cervical samples. Methods Real time quantitative PCR for presence of TV, 18 HPV types and Pap smear analysis of cytologic abnormalities. Main Outcome Measures Association of TV and HPV with cervix dysplasia Results The overall prevalence of TV DNA was 0.37%, of low risk HPV 2%, of high risk HPV 13.2%, and 8.8 % had cytological abnormalities. Both LR-HPV and HR-HPV were significantly associated with all cytological abnormalities. Presence of TV was associated with LR- and HR-HPV, ASC-US and HSIL, but not with other abnormalities. All women with TV and HSIL also had HR-HPV, while the latter was present in only 59% of women with TV and ASC-US. Amongst HPV negative women, TV was found in 1.3% of women with ASC-US, but only in 0.03% of women with normal cytology (OR 4.2, CL95% 2.1-8.6). In HR-HPV positive women, presence of TV increased the likelihood of cytological abnormalities somewhat (P=0.05), mainly due to an increase in ASC-US and LSIL, but not HSIL. Conclusions We conclude that TV infection is associated with both LR and HR-HPV infection of the cervix, as well as with ASC-US and HSIL. TV is a concomitant STI, but is not thought to be a co-factor in the causation of HSIL and cervical cancer. However, TV may cause false positive diagnoses of ASC-US.
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Affiliation(s)
- Gilbert G. G. Donders
- Departments of Obstetrics and Gynecology, University Hospital Antwerpen, Antwerpen, Belgium
- Department of Obstetrics and Gynecology, Heilig Hart Regional Hospital, Tienen, Belgium
- Department Clinical Research for Women, Tienen, Belgium
- * E-mail:
| | - Christophe E. Depuydt
- Laboratory for Molecular and Clinical Pathology (RIATOL), AML Laboratory Sonic Healthcare Benelux, Antwerp, Belgium
| | - John-Paul Bogers
- Laboratory for Molecular and Clinical Pathology (RIATOL), AML Laboratory Sonic Healthcare Benelux, Antwerp, Belgium
| | - Annie J. Vereecken
- Laboratory for Molecular and Clinical Pathology (RIATOL), AML Laboratory Sonic Healthcare Benelux, Antwerp, Belgium
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Marconi C, Donders GGG, Bellen G, Brown DR, Parada CMGL, Silva MG. Sialidase activity in aerobic vaginitis is equal to levels during bacterial vaginosis. Eur J Obstet Gynecol Reprod Biol 2013; 167:205-9. [PMID: 23375395 DOI: 10.1016/j.ejogrb.2012.12.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/05/2012] [Accepted: 12/01/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate levels of proinflammatory cytokines and sialidase activity in aerobic vaginitis (AV) in relation to normal vaginal flora and bacterial vaginosis (BV). STUDY DESIGN In this cross-sectional study, a total of 682 consecutive non-pregnant women attending the gynecology service were assessed and 408 women were included. Vaginal rinsing samples were collected from 223 women with microscopic finding of BV (n=98), aerobic vaginitis (n=25) and normal flora (n=100). Samples were tested for interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor (TNF)-α, and sialidase activity. RESULTS Compared to women with normal flora, vaginal levels of IL-1β were highly increased in both BV and AV (p<0.0001). Significantly higher vaginal IL-6 was detected in AV (p<0.0001) but not in BV, in relation to normal flora. Women with AV also presented increased IL-8 levels (p<0.001), while those with BV presented levels similar to normal flora. Sialidase was increased in BV and AV compared with the normal group (p<0.0001) but no difference in sialidase activity was observed between BV and AV. CONCLUSION A more intense inflammatory host response occurs for AV than for BV when compared with normal flora. Furthermore, the increased sialidase activity in AV and BV indicates that both abnormal vaginal flora types can be harmful to the maintenance of a healthy vaginal environment.
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Affiliation(s)
- C Marconi
- Department of Pathology, Botucatu Medical School, UNESP - Univ Estadual Paulista, Brazil
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Drell T, Lillsaar T, Tummeleht L, Simm J, Aaspõllu A, Väin E, Saarma I, Salumets A, Donders GGG, Metsis M. Characterization of the vaginal micro- and mycobiome in asymptomatic reproductive-age Estonian women. PLoS One 2013; 8:e54379. [PMID: 23372716 PMCID: PMC3553157 DOI: 10.1371/journal.pone.0054379] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/11/2012] [Indexed: 12/16/2022] Open
Abstract
The application of high-throughput sequencing methods has raised doubt in the concept of the uniform healthy vaginal microbiota consisting predominantly of lactobacilli by revealing the existence of more variable bacterial community composition. As this needs to be analyzed more extensively and there is little straightforward data regarding the vaginal mycobiome of asymptomatic women we aimed to define bacterial and fungal communities in vaginal samples from 494 asymptomatic, reproductive-age Estonian women. The composition of the vaginal microbiota was determined by amplifying bacterial 16S rRNA and fungal internal transcribed spacer-1 (ITS-1) regions and subsequently sequencing them using 454 Life Sciences pyrosequencing. We delineated five major bacterial community groups with distinctive diversity and species composition. Lactobacilli were among the most abundant bacteria in all groups, but also members of genus Gardnerella had high relative abundance in some of the groups. Microbial diversity increased with higher vaginal pH values, and was also higher when a malodorous discharge was present, indicating that some of the women who consider themselves healthy may potentially have asymptomatic bacterial vaginosis (BV). Our study is the first of its kind to analyze the mycobiome that colonizes the healthy vaginal environment using barcoded pyrosequencing technology. We observed 196 fungal operational taxonomic units (OTUs), including 16 OTUs of Candida spp., which is more diverse than previously recognized. However, assessing true fungal diversity was complicated because of the problems regarding the possible air-borne contamination and bioinformatics used for identification of fungal taxons as significant proportion of fungal sequences were assigned to unspecified OTUs.
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MESH Headings
- Adolescent
- Adult
- Asymptomatic Diseases
- Candida/classification
- Candida/genetics
- Candida/isolation & purification
- DNA, Intergenic/classification
- DNA, Intergenic/genetics
- Estonia/epidemiology
- Female
- Gardnerella vaginalis/classification
- Gardnerella vaginalis/genetics
- Gardnerella vaginalis/isolation & purification
- Humans
- Lactobacillus/classification
- Lactobacillus/genetics
- Lactobacillus/isolation & purification
- Metagenome/genetics
- Phylogeny
- Polymerase Chain Reaction
- RNA, Ribosomal, 16S/classification
- RNA, Ribosomal, 16S/genetics
- Sequence Analysis, DNA
- Vagina/microbiology
- Vaginal Discharge/microbiology
- Vaginosis, Bacterial/diagnosis
- Vaginosis, Bacterial/epidemiology
- Vaginosis, Bacterial/microbiology
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Affiliation(s)
- Tiina Drell
- Centre for Biology of Integrated Systems, Tallinn University of Technology, Tallinn, Estonia.
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Vedmedovska N, Rezeberga D, Teibe U, Zodzika J, Donders GGG. Adaptive changes in the splenic artery and left portal vein in fetal growth restriction. J Ultrasound Med 2012; 31:223-229. [PMID: 22298865 DOI: 10.7863/jum.2012.31.2.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether a low splenic artery pulsatility index (PI) and reduced flow through the left portal vein are involved in redistribution of fetal growth restriction. METHODS Forty-two women with prenatally diagnosed intrauterine growth restriction of singleton fetuses were included. The next pregnant woman with an appropriately growing fetus, matched for gestational age, was selected as a control. Blood flow velocities were measured in the splenic artery and left portal vein. Obstetric and perinatal information was obtained from standardized medical records. RESULTS The blood flow through the left portal vein was significantly reduced compared with the controls (P < .0001). Placental impairment in fetal growth restriction was clearly linked to a decreased splenic artery PI (P = .0004). In growth-restricted fetuses with reduced left portal vein flow and a splenic artery PI below the 5th percentile, perinatal mortality, a low 5-minute Apgar score, and neonatal metabolic acidosis were observed significantly more often (P = .04, .01, and .004; P = .03, .03, and .006, respectively). CONCLUSIONS Reduced blood flow through the left portal vein and low resistance in the splenic artery can be found in growth-restricted fetuses with adverse neonatal outcomes.
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Affiliation(s)
- Natalija Vedmedovska
- Department of Obstetrics and Gynecology, Riga Stradins University, 16 Dzirciema St, LV1013 Riga, Latvia.
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Donders GGG, Andabati G, Donders F, Michiels T, Eggermont N, Bellen G, Lulé J. Acceptance of self-testing for increased vaginal pH in different subsets of Ugandan women. Int J STD AIDS 2012; 23:30-5. [DOI: 10.1258/ijsa.2011.011190] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We assessed the acceptance of self-testing for vaginal pH in 344 Ugandan women in different clinical settings. Women tested themselves by insertion of a gloved finger into the vagina to test vaginal pH and provide a smear on a glass slide. None of the tested women found the test very difficult: 8% found it somewhat difficult, 16% rather easy and 76% very easy to do. Of the 20% who found it difficult to read the test result, more women were attending a family planning clinic or had a higher diploma ( P = 0.001). Pregnant women were least likely to understand of the meaning of the test, while those visiting family planning clinics had the opposite experience. HIV-infected women were most motivated to accept: 95% would be happy to use the test more often if requested, and another 3.5% felt they might be better motivated to do repeat testing after extra explanation. Self-sampling of vaginal pH is well accepted by Ugandan women. Our new method also allows diagnostic work-up by formal microscopy. Before commencing large-scale population screening, unexpected reactions of different subpopulations should be taken into account.
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Affiliation(s)
- G G G Donders
- Department of Ob/Gyn, University Hospital, Gasthuisberg, Leuven
- H Hart Hospital, Tienen
- Femicare Clinical Research for Women, Tienen, Belgium
| | - G Andabati
- Department of Ob/Gyn, Mulago Hospital, Kampala, Uganda
| | - F Donders
- Femicare Clinical Research for Women, Tienen, Belgium
| | - T Michiels
- Femicare Clinical Research for Women, Tienen, Belgium
| | - N Eggermont
- Femicare Clinical Research for Women, Tienen, Belgium
| | - G Bellen
- Femicare Clinical Research for Women, Tienen, Belgium
| | - J Lulé
- Department of Ob/Gyn, Mulago Hospital, Kampala, Uganda
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Marconi C, de Andrade Ramos BR, Peraçoli JC, Donders GGG, da Silva MG. Amniotic Fluid Interleukin-1 Beta and Interleukin-6, but not Interleukin-8 Correlate with Microbial Invasion of the Amniotic Cavity in Preterm Labor. Am J Reprod Immunol 2011; 65:549-56. [DOI: 10.1111/j.1600-0897.2010.00940.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Vedmedovska N, Rezeberga D, Teibe U, Melderis I, Donders GGG. Placental pathology in fetal growth restriction. Eur J Obstet Gynecol Reprod Biol 2010; 155:36-40. [PMID: 21183268 DOI: 10.1016/j.ejogrb.2010.11.017] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 10/31/2010] [Accepted: 11/28/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES One of the causes of intrauterine fetal growth restriction (FGR) can be pathology of the placenta. The aim of this study was to compare macroscopic and microscopic changes of the placentas from intrauterine growth restricted fetuses with those from normally developed fetuses, in order to test the hypothesis that vascular damage due to decreased maternal vascular perfusion may be responsible for FGR. STUDY DESIGN Between May 2007 and December 2008 we performed detailed macroscopic and histological examination of singleton placentas of 50 consecutive neonates with fetal growth restriction (FGR group) and compared them to 50 normal fetuses, born next to an FGR case, as a control group. RESULTS Gestational age, birth weight, spontaneous delivery rate, mean weight of the placenta and the fetal-placental weight ratio were all lower in the FGR group than in the control group (p<0.05). Thickening of the villous trophoblastic basal membrane, incidence of villous infarction, presence of thrombi or haematomas and the incidence of villitis were more common in the FGR group than in the controls (p<0.05). There were, however, no significant differences in perivillous fibrin deposition, stromal fibrosis and cytotrophoblast proliferation between the groups. In FGR women who smoked, intervillous haematomas and villous infarction were more common (p<0.05) than in controls. CONCLUSIONS All macroscopic and microscopic pathological changes associated with FGR were directly linked to reduction of placental blood flow. As smoking is a main risk factor for these placental abnormalities these results emphasize the need to persuade women to quit smoking not only during pregnancy, but even better long before pregnancy.
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Affiliation(s)
- Natalija Vedmedovska
- Department of Obstetrics and Gynaecology, Riga Stradins University, Riga, Latvia.
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Vedmedovska N, Rezeberga D, Teibe U, Melderis I, Donders GGG. Microscopic lesions of placenta and Doppler velocimetry related to fetal growth restriction. Arch Gynecol Obstet 2010; 284:1087-93. [DOI: 10.1007/s00404-010-1781-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 11/12/2010] [Indexed: 10/18/2022]
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Donders GGG. In the general gynecological literature, communications about infections in obstetrics and gynecology are certainly not in proportion with the frequency and severity of the pathology as we encounter it every day in our clinical practice. Gynecol Obstet Invest 2010; 70:221-3. [PMID: 21051839 DOI: 10.1159/000314009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Donders GGG, Berger J, Heuninckx H, Bellen G, Cornelis A. Vaginal flora changes on Pap smears after insertion of levonorgestrel-releasing intrauterine device. Contraception 2010; 83:352-6. [PMID: 21397094 DOI: 10.1016/j.contraception.2010.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 08/06/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND The levonorgestrel intrauterine system (LNG-IUS) combines a uterine foreign body and the continuous release of low-dose levonorgestrel for contraception. Its influence on the rate of vulvovaginal infections and flora disturbance is insufficiently known, but important for contraceptive advice in women, especially those who develop recurrent vaginosis or Candida vulvovaginitis. STUDY DESIGN Slides of 286 women who had a Pap smear taken before and 1 to 2 years after placement of a LNG-IUS were blindly reviewed for the presence of abnormal vaginal flora (AVF), bacterial vaginosis (BV), aerobic vaginitis (AV) and Candida vaginitis (CV). RESULTS Prior to insertion, there were no differences in vaginal flora abnormalities between women using different kinds of contraception. LNG-IUS users did not have different rates of AVF, BV, AV or CV, but the general risk to develop any infection was increased. Uterine bleeding after insertion did not seem to predict a different flora type. CONCLUSION We found that Pap smears suggested more vaginal infections after 1 year of LNG-IUS use than prior to insertion of the device.
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Donders GGG, Van Keirsbilck J, De Roo T, Schreven L, Hanssens M. Non-cardiogenic lung edema in a woman treated with atosiban for preterm labor. J Perinat Med 2009; 36:455-7. [PMID: 18605966 DOI: 10.1515/jpm.2008.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Biagi E, Vitali B, Pugliese C, Candela M, Donders GGG, Brigidi P. Quantitative variations in the vaginal bacterial population associated with asymptomatic infections: a real-time polymerase chain reaction study. Eur J Clin Microbiol Infect Dis 2008; 28:281-5. [PMID: 18762999 DOI: 10.1007/s10096-008-0617-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 07/30/2008] [Indexed: 10/21/2022]
Abstract
The real-time polymerase chain reaction (PCR) quantification of several vaginal bacterial groups in healthy women and patients developing asymptomatic bacterial vaginosis (BV) and candidiasis (CA) was performed. Statistical analysis revealed that the BV condition is characterised by a great variability among subjects and that it is associated with a significant increase of Prevotella, Atopobium, Veillonella and Gardnerella vaginalis, and a drop in Lactobacillus. On the contrary, the vaginal microflora of healthy women and patients developing CA was found to be homogeneous and stable over time.
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Affiliation(s)
- E Biagi
- Department of Pharmaceutical Sciences, University of Bologna, Via Belmeloro 6, 40126 Bologna, Italy
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Donders GGG, Babula O, Bellen G, Linhares IM, Witkin SS. Mannose-binding lectin gene polymorphism and resistance to therapy in women with recurrent vulvovaginal candidiasis. BJOG 2008; 115:1225-31. [DOI: 10.1111/j.1471-0528.2008.01830.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Vitali B, Pugliese C, Biagi E, Candela M, Turroni S, Bellen G, Donders GGG, Brigidi P. Dynamics of vaginal bacterial communities in women developing bacterial vaginosis, candidiasis, or no infection, analyzed by PCR-denaturing gradient gel electrophoresis and real-time PCR. Appl Environ Microbiol 2007; 73:5731-41. [PMID: 17644631 PMCID: PMC2074899 DOI: 10.1128/aem.01251-07] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The microbial flora of the vagina plays a major role in preventing genital infections, including bacterial vaginosis (BV) and candidiasis (CA). An integrated approach based on PCR-denaturing gradient gel electrophoresis (PCR-DGGE) and real-time PCR was used to study the structure and dynamics of bacterial communities in vaginal fluids of healthy women and patients developing BV and CA. Universal eubacterial primers and Lactobacillus genus-specific primers, both targeted at 16S rRNA genes, were used in DGGE and real-time PCR analysis, respectively. The DGGE profiles revealed that the vaginal flora was dominated by Lactobacillus species under healthy conditions, whereas several potentially pathogenic bacteria were present in the flora of women with BV. Lactobacilli were the predominant bacterial population in the vagina for patients affected by CA, but changes in the composition of Lactobacillus species were observed. Real-time PCR analysis allowed the quantitative estimation of variations in lactobacilli associated with BV and CA diseases. A statistically significant decrease in the relative abundance of lactobacilli was found in vaginal fluids of patients with BV compared to the relative abundance of lactobacilli in the vaginal fluids of healthy women and patients with CA.
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Affiliation(s)
- Beatrice Vitali
- Department of Pharmaceutical Sciences, CIRB-Center for Biotechnology, University of Bologna, Bologna, Italy
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Rezeberga D, Lazdane G, Donders GGG. The impact of social factors on attendance at antenatal care services and the subsequent effect on mothers’ health, measured during the years of economic transition in Latvia. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s11296-007-0063-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Donders GGG, Caeyers T, Tydhof P, Riphagen I, van den Bosch T, Bellen G. Comparison of two types of dipsticks to measure vaginal pH in clinical practice. Eur J Obstet Gynecol Reprod Biol 2006; 134:220-4. [PMID: 16952417 DOI: 10.1016/j.ejogrb.2006.07.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2005] [Revised: 06/11/2006] [Accepted: 07/03/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To assess the practical use of two dispsticks for measuring vaginal pH with a range 4-7 (Merck and Macherey Nagel in the diagnosis of vaginal infections. STUDY DESIGN Routine gynaecological clinic in the General Hospital H Hart in Tienen and vulvo-vaginitis clinic in the University Hospital Gasthuisberg in Leuven, Belgium. After oral consent was obtained, 101 unselected consecutive women presenting for gynaecologic examination between 15 January 2004 and 15 February 2004 were included in an observational study. Vaginal smears were taken from the upper vaginal wall for pH measurement and for fresh wet mount examination by phase contrast microscopy for diagnosing lactobacillary grades and presence of pathogens. The observed color change of two different pH strips were compared with the color scale provided by the company by a junior investigator who was not familiar with the technique, nor with the pathology of the patient. The difficulty of the measurement was scored semi-quantitatively by assessing the time and effort necessary to decide on the correct pH. RESULTS Using the Macherey-Nagel method, the mean pH score was lower in women with normal flora and in women with vaginal infections than when the Merck method was used, but the difference was not significant. The pH became progressively more abnormal with increasing lactobacillary grades, a correlation that was similar for both tests. The reading of the pH sticks was significantly simpler and quicker with Macherey-Nagel than with Merck. Although difficult readings with Merck strips were four times more frequent in the group of women with abnormal flora than in women with normal flora, this difference was not significant. CONCLUSION (1) In both tests (Macherey-Nagel and Merck) the pH was more abnormal (higher) with increasing lactobacillary grades (declining number of lactobacillary morphotypes). (2) The Macherey-Nagel sticks are more user-friendly than Merck's.
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Affiliation(s)
- Gilbert G G Donders
- Department of Obstetrics and Gynecology, General Hospital H Hart Tienen, Belgium.
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Abstract
PURPOSE OF REVIEW To examine and evaluate ways of managing genital infections in pregnant women. RECENT FINDINGS The need to screen for sexually transmitted diseases during pregnancy depends on the prevalence of the condition, its pathogenesis and the cost-benefit analysis for a population or risk group. For a few genital infections with severe impact on the outcome of the pregnancy, such as syphilis and gonorrhoea, a 'screen and treat' policy is almost always cost-effective. SUMMARY Genital infections often remain unnoticed during pregnancy, as their signs and symptoms may be seen as part of the normal discomfort of pregnancy. Also it is sometimes not clear whether there are multiple partners or whether the partners have been treated, making re-infection after treatment highly likely. Partner tracing may be difficult, but the 'screen and treat' policy is usually the best solution.
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Affiliation(s)
- Gilbert G G Donders
- Department of Obstetrics and Gynecology, General Hospital Heilig Hart Tienen, and Gasthuisberg University Hospital, Katholieke Universiteit Leuven, Tienen, Belgium.
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Abstract
OBJECTIVE The purpose of this study was to determine whether the vaginal cytokine concentration varies during the course of uncomplicated pregnancy. STUDY DESIGN Prenatal visits of healthy women to University Hospital Gasthuisberg, Leuven, Belgium were considered. Cytokine levels in vaginal washings from 30 unselected healthy women with uncomplicated pregnancies were monitored during pregnancy and compared with those from 62 nonpregnant healthy control subjects. Exclusion criteria included bacterial vaginosis, moderate or severe aerobic vaginitis, Trichomonas vaginalis, Candida vaginitis (wet mount or culture), gonorrhea, and Chlamydia. Interleukin-6, interleukin-8, interleukin-1beta, interleukin-1-receptor antagonist, leukemia inhibitory factor, and tumor necrosis factor were measured. Nonparametric Kruskal-Wallis and Welch tests were used for univariate analysis, and the Spearman rank test was used for multivariate analysis. RESULTS Compared with concentrations in nonpregnant women, interleukin-1beta concentrations were similar, but interleukin-1-receptor antagonist production was depressed throughout pregnancy. Vaginal interleukin-6 and interleukin-8 were less often discovered during pregnancy than outside pregnancy and dipped significantly in the middle trimester, to rise again to prepregnancy levels in the third trimester. Leukemia inhibitory factor was lower during the beginning of pregnancy (P=.038) but otherwise did not differ from nonpregnant values throughout pregnancy nor did tumor necrosis factor. Sexual activity could not explain these findings. CONCLUSION Vaginal cytokine levels, especially interleukin-1 receptor antagonist, from pregnant women may differ from nonpregnant values; some levels, such as interleukin-6 and interleukin-8, may fluctuate during normal pregnancy. These spontaneous variations during pregnancy must be taken into account when mucosal immunologic responses to infection of the lower genital tract are being studied.
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Affiliation(s)
- Gilbert G G Donders
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Herestraat 45, Leuven 3000, Belgium.
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Van den Bosch T, Donders GGG, Riphagen I, Debois P, Ameye L, De Brabanter J, Van Huffel S, Van Schoubroeck D, Timmerman D. Ultrasonographic features of the endometrium and the ovaries in women on etonogestrel implant. Ultrasound Obstet Gynecol 2002; 20:377-380. [PMID: 12383321 DOI: 10.1046/j.1469-0705.2002.00816.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate the ultrasound features of the endometrium and ovaries in women on etonogestrel implant, and to correlate these features with the bleeding pattern. METHODS Observational study including 188 consecutive women presenting for follow-up transvaginal ultrasound examination after insertion of an etonogestrel implant contraceptive device. Thirty women had more than one follow-up examination. The bleeding pattern was considered abnormal if, in the last 3 months, there were more than five episodes of vaginal bleeding, or there was prolonged bleeding exceeding 14 consecutive days. RESULTS At first follow-up examination, the mean age was 29.7 years and 47% of women had an abnormal bleeding pattern. Most bleeding episodes were of less intensity than menses. The mean endometrial thickness (ET) on ultrasound was 2.9 mm (standard deviation, 2.0). Ovarian follicle growth exceeding 5 mm was observed in 60% of the cases. Ovulation was demonstrated in one woman. Univariate analysis showed a positive association (P < 0.01) between ET, bleeding pattern, and bleeding intensity. Follicle growth was positively associated (P < 0.01) with ET, bleeding pattern, and interval between insertion and examination. Multivariate analysis showed that the ET was on average 1.25 mm greater in women with abnormal bleeding (P = 0.0001). The odds of finding follicle growth were 2.8 times higher (95% confidence interval, 1.2-6.2) in women presenting with a three-layer type of endometrial morphology. There was no association between the other patients' characteristics and the bleeding pattern. CONCLUSIONS Abnormal uterine bleeding in women on etonogestrel implant was associated with follicle growth and a thicker, three-layer type of endometrium, suggesting incomplete ovarian inhibition and estrogen stimulation of the endometrium.
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Affiliation(s)
- T Van den Bosch
- Department of Obstetrics and Gynecology of AZ Heilig Hart, Tienen, Belgium.
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