Key Factors to Consider in Team Meetings when Dealing with Multimorbidity in Primary Care: Results from a Delphi Panel

BACKGROUND

Multimorbidity brings several difficulties and challenges to the daily work of primary care teams. Team meetings are opportunities to discuss approaches and solutions on how to best manage multimorbid patients.

OBJECTIVE

This qualitative study aimed to collect a consensus, from general practitioners that deal with multimorbid patients, about their perspectives regarding multimorbidity team meetings in primary care.

METHODS

The study followed a modified Delphi method with 15 Portuguese general practitioners. After every round of responses, results were analyzed, and justifications for non-consensual items were aggregated by the investigators, and then a new Delphi round with the revised questionnaire was again initiated. This process was repeated until consensus has been reached.

RESULTS

Overall, a list of 10 key themes associated with the ideal meeting was agreed: (a) definition; (b) setting; (c) duration; (d) frequency; (e) number of participants; (f) attendance; (g) requirement of patient's presence; (h) number of patients/clinical cases; (i) structure of the meeting; and (j) sharing meeting results. The consensus was achieved after two Delphi rounds with a mean score between 7.9 and 8.7 (maximum score of 9.0 per key theme).

CONCLUSION

The complexity of multimorbidity affects meetings' periodicity, duration, and participants. Ideally, it should be an interprofessional primary care team meeting. Further research exploring meeting outcomes (organizational effectiveness and healthcare quality) of the proposed factors is needed before they can be recommended for general use.

Microbiological characteristics and inflammatory cytokines associated with preterm labor

PURPOSE

To evaluate vaginal microflora and interleukin-1β (IL-β), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-α) concentrations in the cervicovaginal fluid of a group of pregnant women in preterm labor when compared with a group of full-term pregnant women not yet in labor.

METHOD

Case-control study performed in a University tertiary referral maternity in Campinas, Brazil with 45 pregnant women in preterm labor and 45 full-term pregnant women not in labor. All patients underwent speculum examination for the collection of cervicovaginal fluid. Bacterial vaginosis (BV) was diagnosed according to the criteria of Amsel and Nugent. Culture was performed for group B streptococcus (GBS) and lactobacilli, and hybrid capture assay for screening for chlamydial and gonococcal infection. Cytokine concentrations were measured using ELISA technique. Statistical analysis was performed using χ(2), Fisher's exact, and crude and adjusted odds ratios. Significance level was defined at 5%. The main outcome measures were cervicovaginal cytokines in preterm labor.

RESULTS

IL-6 and IL-8 were significantly associated with preterm labor. The changes in vaginal microflora, as well as BV and GBS, were more frequent in women in preterm labor, although BV and GBS showed no statistical significance. The presence of Candida sp., absence of lactobacilli, positive screening for chlamydial and gonococcal infection and the presence of IL-1β and TNF-α were not associated with preterm labor.

CONCLUSIONS

IL-6 and IL-8 and the presence of any type of vaginal infection were the factors that were significantly associated with preterm labor.

Effect of mucosal fluid from women with bacterial vaginosis on HIV trans-infection mediated by dendritic cells

Women with bacterial vaginosis (BV) have a higher risk of HIV transmission but the cause of risk is unknown. Dendritic cells (DC) are implicated in transmission of HIV and we previously observed that DC mature when exposed to mucosal fluid from women with BV. We hypothesized that maturation of DC by BV mucosal fluid would enhance DC-mediated trans-infection of HIV. Monocyte-derived DC (MDDC) were treated with mucosal fluid, incubated with HIV(Bal), and HIV trans-infection was evaluated. While LPS-treated MDDC increased HIV(Bal)trans-infection, BV fluid reduced trans-infection. HIV(Bal) DNA levels in MDDC were not affected by BV fluid or LPS but productive infection of MDDC was decreased by LPS and BV fluid. Mucosal fluid from women with BV does not increase MDDC-mediated trans-infection suggesting that BV does not increase HIV susceptibility by increasing DC-mediated trans-infection. However, indirect effects of DC maturation on HIV transmission cannot be ruled out.

Dendritic cell activation and maturation induced by mucosal fluid from women with bacterial vaginosis

Dendritic cells (DC) at mucosal surfaces mature when exposed to "danger" signals such as LPS. Bacterial vaginosis (BV) is a prevalent alteration of the vaginal bacterial flora associated with preterm childbirth and increased risk for HIV acquisition. We examined the effect of mucosal fluid from women with BV or healthy flora on DC function. IL-12, IL-23 and p40 production by monocyte-derived dendritic cells (MDDC) were all induced by BV samples. Activation/maturation markers HLA-DR, CD40 and CD83 on MDDC incubated with BV CVL were also induced. BV CVL also decreased the endocytic ability of MDDC and increased proliferation of T cells in allogeneic MLR. Plasmacytoid dendritic cell (pDC) CD86 expression was induced by BV CVL. Healthy flora CVL had little effect in any of the tests. This study suggests that BV, but not healthy flora, affects local dendritic cell function in vivo suggesting a mechanism through which BV affects mucosal immunity.

TLR2-mediated cell stimulation in bacterial vaginosis

Bacterial vaginosis (BV) is associated with preterm labor, pelvic inflammatory disease (PID) and increased HIV acquisition, although the pathways that mediate these pathological effects have not been elucidated. To determine the presence of Toll-like receptor (TLR)-ligands and their specificity in BV, genital tract fluids were collected from women with and without BV by cervicovaginal lavage (CVL). The CVL samples were evaluated for their ability to stimulate secretion of proinflammatory cytokines and to activate NFkappaB and the HIV long terminal repeat (LTR), indicators of TLR activation, in human monocytic cells. Stimulation with BV CVLs induced higher levels of IL-8 and TNFalpha secretion, as well as higher levels of HIV LTR and NFkappaB activation, than CVLs from women with normal healthy bacterial flora. To identify which TLRs were important in BV, 293 cells expressing specific TLRs were exposed to CVL samples. BV CVLs induced higher IL-8 secretion by cells expressing TLR2 than CVLs from women without BV. Surprisingly, BV CVLs did not stimulate cells expressing TLR4/MD2, although these cells responded to purified lipopolysaccharide (LPS), a TLR4 ligand. BV CVLs, in cells expressing TLR2, also activated the HIV LTR. Thus, these studies show that soluble factor(s) present in the lower genital tract of women with BV activate cells via TLR2, identifying a pathway through which BV may mediate adverse effects.

Management of stress urinary incontinence with surface electromyography-assisted biofeedback in women of reproductive age

BACKGROUND AND PURPOSE

Although surgery has been widely accepted as the treatment of choice for stress urinary incontinence (SUI), there has recently been an increased interest in the conservative management of this condition. The aims of this study were to test the ability of a biofeedback-assisted pelvic-floor muscle exercise (PFME) program to affect symptoms of SUI in premenopausal women and to evaluate a training program that might lead to successful outcomes in a relatively limited number of sessions.

SUBJECTS

Twenty-six women with SUI were treated with PFME with surface electromyography (sEMG)-assisted biofeedback. All participants were of reproductive age and were treated individually for 12 sessions.

METHODS

results were evaluated with a 7-day voiding diary, a 1-hour pad test, pelvic-floor muscle strength measurements, sEMG amplitudes, a leakage index, and a quality-of-life questionnaire. These variables were compared before and after the intervention.

RESULTS

The frequency of urine loss, the occurrence of nocturia, and the number of pads required decreased significantly after the intervention. Objective cure was found in 61.5% of women. There was a significant improvement in the quality of life, in pelvic-floor muscle strength, and in the sEMG amplitudes of all contractions throughout the intervention.

DISCUSSION AND CONCLUSION

A relatively short-term intervention of PFME with sEMG-assisted biofeedback appeared to be helpful in relieving symptoms of SUI in premenopausal women and represents a reasonable conservative management option.

A pilot clinical trial comparing an acid-buffering formulation (ACIDFORM gel) with metronidazole gel for the treatment of symptomatic bacterial vaginosis

AIM

To compare the effectiveness of an acid-buffering formulation gel (ACIDFORM) with metronidazole gel in the treatment of symptomatic bacterial vaginosis (BV).

METHODS

After a confirmed diagnosis of BV according to the criteria established by Nugent and Amsel, 30 nonpregnant women were enrolled in a randomized, double-blind clinical study. The women were randomly assigned to receive either 5 g ACIDFORM gel (n = 13) or 10% metronidazole gel (n = 17) intravaginally once daily for five consecutive days. Participants were evaluated in two follow-up visits (7-12 days and 28-35 days after treatment). Therapeutic success was defined as the presence of less than three of Amsel's criteria. If three or more criteria were present at first or second follow-up visit, the woman was excluded from the study and treated orally with metronidazole. Nugent scores were recorded at each visit but these were not used to define cure.

RESULTS

At the first follow-up visit, 15 (88%) of the women in the metronidazole group were cured compared with only three (23%) in the ACIDFORM group (P < 0.001). The remaining 12 women (10 of the ACIDFORM group and two of the metronidazole group) were considered as failure and were treated orally with metronidazole. At the second follow-up visit, two of the ACIDFORM-treated women and six of the metronidazole-treated women presented recurrent BV. Four women in the ACIDFORM group and one in the metronidazole group reported occasional burning and itching during product use.

CONCLUSION

ACIDFORM gel was significantly less effective than high-dose metronidazole gel for the treatment of symptomatic BV.

Clinical diagnosis of bacterial vaginosis

OBJECTIVE

To evaluate the accuracy of Amsel's criteria individually or in combinations of two for the clinical diagnosis of bacterial vaginosis.

METHODS

This cross-sectional study enrolled 135 women at UNICAMP, and evaluated Amsel's four clinical criteria. Sensitivity, specificity, positive and negative predictive values were calculated for each criterion individually, in combinations of two, and for the classic test with at least three criteria present. The Nugent method was used as gold standard.

RESULTS

The most sensitive individual criteria were pH and vaginal discharge (97%), the latter having lowest specificity (26%). The criterion with highest specificity was the presence of clue cells (86%). The combination of two criteria showed sensitivity of 83% to 93%, and specificity of 82% to 94%.

CONCLUSION

The accuracy of Amsel's clinical criteria individually or in combinations of two was as accurate as the presence of at least three criteria for the diagnosis of bacterial vaginosis.

Is bacterial vaginosis associated with squamous intraepithelial lesion of the uterine cervix?

The objective of this study was to analyze the association between bacterial vaginosis (BV) and squamous intraepithelial lesion (SIL). Pap smears were analyzed to verify the presence of BV and SIL. One hundred and ten women with SIL comprised the study group, while 110 women with no cytological abnormalities served as controls. BV was similarly present in women of both groups: 18% of women with SIL and 12% of women without SIL. Results were also similar when the grade of SIL was taken into consideration. BV was detected in 16% of women with low-grade SIL and in 12% of women in the control group, while a higher rate of BV (33%) was found among women with high-grade SIL in comparison to the controls (12%). This difference, however, was not statistically significant. BV tended to be more common among women with high-grade SIL than in women with no cytological abnormalities.

Presence of 20% or more clue cells: An accurate criterion for the diagnosis of bacterial vaginosis in Papanicolaou cervical smears

A study was carried out in 135 women of reproductive age to evaluate the role of the Papanicolaou smear performed in cervical and vaginal samples for the diagnosis of bacterial vaginosis (BV), to validate the method for this diagnosis and to evaluate the reproducibility of the criterion used. The cervical and vaginal smears were stained using the Papanicolaou method and evaluated by two separate observers. The finding of 20% or more clue cells was considered positive for the presence of BV. This diagnostic criterion presented a sensitivity of 87%, specificity of 94%, a positive predictive value of 81%, and a negative predictive value of 96%, both in cervical and vaginal samples. There was excellent agreement in the diagnosis of BV between the two observers (kappa, 0.87) and between cervical and vaginal samples (kappa, 0.92). Therefore, the presence of 20% or more clue cells in the Papanicolaou smear is an accurate and reproducible criterion for the diagnosis of BV and may be used in screening for this infection, eliminating the need for further vaginal sample collection.

Antibiotic resistance patterns of group B streptococcal clinical isolates

OBJECTIVES: To determine the in vitro resistance of group B streptococcus (GBS) to 12 antibiotics. To determine if there has been any decrease in sensitivity to the penicillins or other antibiotics currently used for GBS chemoprophylaxis in pregnant women. Find suitable alternative antibiotics to penicillin. Find an antibiotic that will have minimal selective pressure for resistance among the endogenous resident vaginal microflora. METHODS: The antibiotic susceptibility profiles of 52 clinical isolates of GBS were evaluated to 12 antibiotics: ampicillin, azithromycin, cefamandole, cefazolin, ceftriaxone, ciprofloxacin, clindamycin, erythromycin, nitrofurantoin, ofloxacin, penicillin and vancomycin. Antibiotic sensitivities were determined using disk diffusion and microdilution methods according to the guidelines of the National Committee for Clinical Laboratory Standards (NCCLS). RESULTS: All isolates were sensitive to vancomycin, ofloxacin, ampicillin, ciprofloxacin, nitrofurantoin and penicillin. However, the following number of clinical isolates exhibited intermediate or decreased sensitivity, nine (17%) to ampicillin, eight (15%) to penicillin, 14 (32%) to ciprofloxacin and one (2%) to nitrofurantoin. Thirty-one percent of the isolates were resistant to azithromycin and ceftriaxone, 19% to clindamycin, 15% to cefazolin and 13% to cefamandole. Eighteen (35%) of the clinical isolates tested were resistant to 6 of the 12 antibiotics tested. CONCLUSIONS: The relatively high rates of resistance for 6 of the 12 antibiotics tested suggest that for women allergic to penicillin and colonized with GBS, antibiotic sensitivities to their isolates should be determined. The antibiotic selected for intrapartum chemoprophylaxis should be guided by the organism's antibiotic sensitivity pattern. Patients with GBS bacteriuria should be treated with nitrofurantoin.

Two novel vaginal microbicides (polystyrene sulfonate and cellulose sulfate) inhibit Gardnerella vaginalis and anaerobes commonly associated with bacterial vaginosis

This is the first report demonstrating the in vitro inhibitory activity of two novel microbicides (cellulose sulfate and polystyrene sulfonate) against bacterial vaginosis (BV)-associated bacteria. Vaginal application of these microbicides not only may reduce the risk of acquisition of human immunodeficiency virus and other sexually transmitted infection-causing organisms but may also decrease the incidence of BV.

Genetic diversity of vaginal lactobacilli from women in different countries based on 16S rRNA gene sequences

AIMS

Lactobacilli are widely distributed in food and the environment, and some colonize the human body as commensal bacteria. The aim of this study was to determine the species of lactobacilli that colonize the vagina and compare them with those found in food and the environment.

METHODS AND RESULTS

Thirty-five Lactobacillus strains from women from seven countries were isolated, and sequences from 16S rRNA genes were determined and compared with existing data in GenBank. A phylogenetic tree was achieved using the Neighbour-Joining method based on the analysis of 1465 nucleotides. The results showed that most vaginal isolates were L. crispatus, L. jensenii and L. gasseri. Some were L. vaginalis, L. fermentum, L. mucosae, L. paracasei and L. rhamnosus. Two isolates from a native American woman displayed distinct branches, indicating novel phylotypes. Few vaginal isolates matched food or environmental Lactobacillus species.

CONCLUSIONS

Most women worldwide were colonized by three common Lactobacillus species: L. crispatus, L. jensenii and L. gasseri.

SIGNIFICANCE AND IMPACT OF THE STUDY

Knowledge of vaginal Lactobacillus species richness and distribution in women worldwide may lead to the design of better probiotic products as bacterial replacement therapy.

Bacteriocin susceptibility of Gardnerella vaginalis and its relationship to biotype, genotype, and metronidazole susceptibility

OBJECTIVE

Our purpose was to investigate the bacteriocin susceptibility of Gardnerella vaginalis and its relationship to biotype, genotype, and resistance to metronidazole.

STUDY DESIGN

Bacteriocin susceptibility of 36 G vaginalis clinical isolates was tested against a vaginal strain of Lactobacillus acidophilus by a growth-inhibition method. The relationship to biotype, genotype, and resistance to metronidazole were analyzed by the chi2 test and Fisher exact test.

RESULTS

Eight G vaginalis strains (22%) were bacteriocin-resistant. Biotypes 5 and 7 were found to be the most frequent among these resistant strains. Eight (42%) of the 19 isolates classified as biotype 5, 6, or 7 were bacteriocin-resistant compared with none of the isolates that were classified as other biotypes (P <.01). Biotype 5 was found in higher prevalence among the isolates resistant to bacteriocin (62%) than among the susceptible isolates (14%) (P =.01). Genotype B was found more frequently among the bacteriocin-resistant strains, but this finding was not statistically significant (P =.71). Seven (88%) bacteriocin-resistant strains were also resistant to metronidazole.

CONCLUSION

An association between biotype and an increased resistance to bacteriocin was found. The ability of G vaginalis to resist the antibacterial activity of Lactobacillus bacteriocin may be a pivotal factor in understanding bacterial vaginosis.

Antimicrobial protein produced by vaginal Lactobacillus acidophilus that inhibits Gardnerella vaginalis

Objective: To isolate bacteriocin from a vaginal strain of Lactobacillus acidophilus.

Methods: L. acidophilus 160 was grown on two media. The first was MRS broth for 18 hours; the cells were harvested, washed, and placed into a chemically defined medium. The second medium resembled vaginal fluid minus protein. Bacteriocin was precipitated from both media using ammonium sulfate. The growth-inhibiting activity of bacteriocin was determined by a bioassay using nine different isolates of Gardnerella vaginalis.

Results: MRS broth is not a suitable medium for extracting bacteriocin, because it binds with Tween 80. Bacteriocin was isolated, without contaminating constituents, from chemically defined medium and identified as a single band by electrophoresis. Bacteriocin has a molecular weight of 3.8 kDa. All nine isolates of Gardnerella were inhibited by the bacteriocin isolated from L. acidophilus 160.

Conclusions: Bacteriocin produced by L. acidophilus 160 was isolated from the chemically defined medium (starvation medium) in a partially pure form. L. acidophilus 160 bacteriocin inhibited growth of all nine isolates of Gardnerella vaginalis.

Effect of metronidazole on the growth of vaginal lactobacilli in vitro

Objective: To determine whether metronidazole has an adverse effect on the growth of Lactobacillus.

Methods: Hydrogen peroxide- and bacteriocin-producing strains of Lactobacillus were used as test strains. Concentrations of metronidazole used ranged from 128 to 7000 μg/ml. Susceptibility to metronidazole was conducted by the broth microdilution method recommended by the National Committee for Clinical Laboratory Standards.

Results: Growth of Lactobacillus was partially inhibited at concentrations between 1000 and 4000 μg/ml (p = 0.014). Concentrations ≥ 5000 μg/ml completely inhibited growth of Lactobacillus. Concentrations between 128 and 256 μg/ml stimulated growth of Lactobacillus (p = 0.025 and 0.005, respectively). Concentrations of metronidazole between 64 and 128 μg/ml or ≥ 512 μg/ml did not have an inhibitory or a stimulatory effect on the growth of Lactobacillus compared to the control.

Conclusions: High concentration of metronidazole, i.e. between 1000 and 4000 μg/ml, partially inhibited the growth of Lactobacillus. Concentrations ≥ 5000 μg/ml completely suppressed the growth of Lactobacillus. Concentrations between ≥ 128 and ≤ 256 μg/ml stimulated the growth of Lactobacillus. Further investigation to determine the ideal concentration of metronidazole is needed in order to use the antimicrobial agent effectively in the treatment of bacterial vaginosis.

Gardnerella vaginalis isolated from patients with bacterial vaginosis and from patients with healthy vaginal ecosystems

The differences in the phenotype and genotype of Gardnerella vaginalis isolates from patients with bacterial vaginosis (BV) and from patients without BV are unknown. In our study, 43 isolates of G. vaginalis were examined for biotype (hippurate hydrolysis, lipase, and beta-galactosidase activity), sensitivity to metronidazole, and genotype. Of the 117 women visiting the gynecology clinic at Rush-Presbyterian-St. Luke's Medical Center who were included in the study, 27.4% were found to have BV. G. vaginalis was found in samples from 87.5% of women with BV, from 34.0% of women with intermediate BV, and from 26.4% of women with healthy vaginal ecosystems. Among patients with G. vaginalis, biotypes 7 and 8 were isolated from 32% and 20% of patients, respectively. Biotype 5 was predominantly associated with a healthy vaginal ecosystem (P=.0004). Biotypes 5 and 7 were the most resistant to metronidazole. No specific phenotype or genotype of G. vaginalis causes BV.

Defense factors of vaginal lactobacilli

OBJECTIVE

To determine the antagonistic relationship between vaginal lactobacilli and endogenous vaginal microflora.

STUDY DESIGN

Twenty-two Lactobacillus strains were studied for the production of lactic acid, hydrogen peroxide, and bacteriocin.

RESULTS

Under standardized growth conditions, most strains increased their biomass by more than 4 times. Lactobacillus species grew best at a pH > or = 4.5, and growth was retarded at a pH < 4.5. Lactic acid levels were 0.68 to 2.518 mg/mL and were not related to the number of cells or the pH of media. The pH of the media was caused by the secretion of lactic and other organic acids. Approximately 80% of the strains produced H(2)O(2) and were graded as 2+ in one third of the strains and 1+ in others. No statistical correlation was found between H(2)O(2) lactic acid and bacteriocin production. Bacteriocin activity was tested on 4 strains of Gardnerella vaginalis. Approximately 80% of the lactobacilli tested produced bacteriocin that inhibited growth of G vaginalis. Six of the strains did not produce bacteriocin. Thirteen strains produced all 3 defense factors, whereas the others lacked 1 or 2 properties.

CONCLUSIONS

Lactobacillus species grow best at a pH > 4.5. The pH of the media is dependent on the cell mass and on all organic acids produced by Lactobacillus species. Although all species produce organic acids, not all produce H(2)O(2) and bacteriocin. Not all strains of G vaginalis can be inhibited by lactobacilli-producing bacteriocin.

Human immunodeficiency virus type 1 stimulatory activity by Gardnerella vaginalis: relationship to biotypes and other pathogenic characteristics

Stimulation of human immunodeficiency virus (HIV) type 1 expression by Gardnerella vaginalis is one possible cause for an increase in the amount of virus in the genital tract. The ability of G. vaginalis to induce HIV expression in chronically infected U1 cells was investigated, along with its possible relationship to biotype, genotype, and resistance to metronidazole and bacteriocin. Significant HIV stimulatory activity was found in 5 (50%) lysates of G. vaginalis. The ability to induce HIV expression in U1 cells was statistically associated with G. vaginalis biotype (P=.048) but not with genotype or resistance to metronidazole and bacteriocin. Further studies to explore the in vivo relevance of HIV activation by G. vaginalis in the female genital tract are warranted, since prevention strategies of bacterial vaginosis and colonization by certain biotypes of G. vaginalis may be valuable in reducing the risk of sexual transmission of HIV.

The inhibitory effect of clindamycin on Lactobacillus in vitro

OBJECTIVE

To evaluate the in vitro effect of varying concentrations of clindamycin on Lactobocillus spp.

METHODS

Concentrations of clindamycin ranging from 1.95-20,000 microg/ml were studied for their effect on the growth of six strains of Lactobacillus.

RESULTS

Clindamycin concentrations between 1.95-31.25 microg/ml had no statistically significant effect on growth of lactobacilli (p > 0.05). Concentrations 125 and 250 microg/ml had a bacteriostatic effect. The mean minimum inhibitory concentration (MIC) for studied Lactobacillus strains was determined as 1,000 microg/ml.

CONCLUSION

High concentrations of clindamycin achieved in the vagina by intravaginal application might be inhibitory for Lactobacillus.