WEBVTT 1 00:00:08.508 --> 00:00:08.908 Hello. 2 00:00:08.908 --> 00:00:12.946 My name is Alex Shakir and I'm a medical director at R u B laboratories 3 00:00:13.213 --> 00:00:14.581 and an assistant professor 4 00:00:14.581 --> 00:00:17.584 at the University of Utah and the Department of Pathology. 5 00:00:17.717 --> 00:00:21.554 I'm here to discuss today a common but important women's health issue, 6 00:00:21.554 --> 00:00:25.525 opportunities and diagnostic considerations, including molecular 7 00:00:25.525 --> 00:00:28.528 testing for the major pathogens associated with it. 8 00:00:31.097 --> 00:00:32.399 The objective for today's 9 00:00:32.399 --> 00:00:35.435 presentation, we'll cover an introduction to virginity 10 00:00:35.702 --> 00:00:39.873 and then a review of the three most common causes of tinnitus, 11 00:00:39.973 --> 00:00:44.411 including bacterial vaginosis Canada, Virgin Iris and Czech homeowners. 12 00:00:44.411 --> 00:00:45.812 About analysis. 13 00:00:45.812 --> 00:00:49.949 We will discuss the various diagnostic options from in-office 14 00:00:49.949 --> 00:00:53.720 point of care test to those performed in a clinical laboratory setting. 15 00:00:54.254 --> 00:00:57.924 And then wrap up this presentation with the significance of co-infections 16 00:00:58.124 --> 00:01:01.127 with other sexually transmitted infections. 17 00:01:02.495 --> 00:01:05.498 So what is vagina is and how is it defined? 18 00:01:05.598 --> 00:01:08.601 It is an inflammation or infection of the vagina. 19 00:01:09.369 --> 00:01:13.173 It is associated with a wide variety of symptoms, including itching, 20 00:01:13.173 --> 00:01:18.044 burning, irritation, a bad odor, and abnormal vaginal discharge. 21 00:01:19.179 --> 00:01:19.679 In some 22 00:01:19.679 --> 00:01:22.682 individuals, the discharge can appear as clear, gray 23 00:01:22.682 --> 00:01:25.685 or green, frothy or colored like, and white. 24 00:01:26.886 --> 00:01:29.889 It can be caused by pathogens that are sexually transmitted 25 00:01:30.623 --> 00:01:33.359 and is also associated with HIV 26 00:01:33.359 --> 00:01:36.362 and acquisition of other STIs. 27 00:01:37.664 --> 00:01:38.665 If undiagnosed 28 00:01:38.665 --> 00:01:42.001 and untreated, Virginias can lead to endometriosis, 29 00:01:42.001 --> 00:01:45.004 which is an inflammation of the inner lining of the uterine wall, 30 00:01:45.438 --> 00:01:48.608 or also pelvic inflammatory disease and infertility. 31 00:01:49.876 --> 00:01:50.944 In pregnancy. 32 00:01:50.944 --> 00:01:54.214 It can lead to adverse outcomes such as low birth weight 33 00:01:54.214 --> 00:01:57.183 or premature birth. 34 00:01:58.451 --> 00:01:59.486 So when we are thinking 35 00:01:59.486 --> 00:02:04.023 about the differentials of genetics, we can think of it in two broad categories 36 00:02:04.724 --> 00:02:07.727 infectious or non infectious causes 37 00:02:08.094 --> 00:02:11.831 for infectious vaccinated is the most common causes are bacterial 38 00:02:11.831 --> 00:02:16.803 vaginosis, Candida, Virginias or bulbbul, vaginal candidiasis, 39 00:02:17.303 --> 00:02:21.307 Chik harmonizes, and other STI such as chlamydia, gonorrhea or herpes. 40 00:02:22.308 --> 00:02:23.209 For noninfectious 41 00:02:23.209 --> 00:02:27.013 vaginismus, we can think of but not have anything 42 00:02:27.013 --> 00:02:31.117 that can cause an allergic reaction a foreign body like a tampon 43 00:02:31.384 --> 00:02:34.387 or some chronic skin conditions like lichen placed in this. 44 00:02:36.489 --> 00:02:37.891 About 90% of Virginia. 45 00:02:37.891 --> 00:02:40.660 This is due to bacterial vaginosis. 46 00:02:40.660 --> 00:02:43.663 Candida Vegemite is an took home analysis. 47 00:02:43.663 --> 00:02:47.066 Bacterial vaginosis alone is the most common of the three, 48 00:02:47.300 --> 00:02:52.906 with about 30 to 50% of virgin cases, and this is followed by Canada. 49 00:02:52.906 --> 00:02:57.277 Virginia is accounting for approximately 25 to 30% of cases 50 00:02:58.511 --> 00:03:00.613 and harmonizes, 51 00:03:00.613 --> 00:03:04.784 which is caused by the first wave Flagler took homeowners causes. 52 00:03:04.784 --> 00:03:07.754 About 15% of cases of Virgin itis. 53 00:03:08.521 --> 00:03:11.858 These can either be single infections or mixed, 54 00:03:11.858 --> 00:03:16.196 and co-infections are pretty common in about 20 to 30% individuals. 55 00:03:17.363 --> 00:03:20.133 In some individuals, these can also be present 56 00:03:20.133 --> 00:03:24.137 with one infection, such as chlamydia, gonorrhea, or mycoplasma. 57 00:03:24.137 --> 00:03:24.938 Genitalia. 58 00:03:28.274 --> 00:03:30.176 Here you can see the different symptoms 59 00:03:30.176 --> 00:03:33.546 and clinical findings for the three main causes of virgin itis, 60 00:03:34.214 --> 00:03:37.183 starting with the appearance of the vaginal discharge, 61 00:03:37.850 --> 00:03:40.587 whether it is clear to white or homogenous 62 00:03:40.587 --> 00:03:43.590 or clumpy, or cottage cheese like, 63 00:03:43.890 --> 00:03:46.893 along with the pH of the vaginal environment, 64 00:03:47.293 --> 00:03:50.296 whether it's less than 4.5 or more, 65 00:03:50.530 --> 00:03:53.533 and why this may be important. 66 00:03:53.700 --> 00:03:56.502 Also, it's important to note if there is any odor 67 00:03:56.502 --> 00:04:01.341 associated with the viral discharge and if microscopy is available, 68 00:04:01.474 --> 00:04:02.976 whether they are inflammatory 69 00:04:02.976 --> 00:04:06.312 cells or close cells, which may indicate vaginal itis. 70 00:04:07.080 --> 00:04:11.718 So these symptoms can be very similar among the main players of Unitas 71 00:04:12.085 --> 00:04:15.755 and create a challenge for accurate clinical diagnosis. 72 00:04:17.824 --> 00:04:20.059 So let's now dive into the major players 73 00:04:20.059 --> 00:04:23.062 of tonight's. 74 00:04:24.097 --> 00:04:25.298 Bacterial vaginosis 75 00:04:25.298 --> 00:04:29.636 is one of the most common vaginal conditions in women ages 15 to 44. 76 00:04:30.870 --> 00:04:33.072 Epidemiological data shows the prevalence 77 00:04:33.072 --> 00:04:36.809 to be about more than 20 million women in the United States, 78 00:04:37.410 --> 00:04:40.380 but a majority of these individuals are asymptomatic. 79 00:04:40.380 --> 00:04:44.284 The prevalence also varies by race or ethnicity. 80 00:04:44.684 --> 00:04:48.421 Where African American women in the US are more than twice likely 81 00:04:48.421 --> 00:04:51.424 to develop bacterial vaginosis compared to Caucasian women, 82 00:04:53.293 --> 00:04:54.627 BV is also known 83 00:04:54.627 --> 00:04:59.032 to be associated with infertility, and the presence of BV was observed 84 00:04:59.032 --> 00:05:03.002 to be significantly higher in infertile women with as fertile women. 85 00:05:05.471 --> 00:05:08.207 Women presenting with BD are seen to have a thin, 86 00:05:08.207 --> 00:05:12.312 homogeneous vaginal discharge, which often have a fishy odor. 87 00:05:13.046 --> 00:05:16.049 This usually worsens after intercourse. 88 00:05:16.416 --> 00:05:18.484 Examination of the virgin discharge 89 00:05:18.484 --> 00:05:21.487 may show a pH of more than 4.5, 90 00:05:21.788 --> 00:05:25.858 a positive with test when you use 10% potassium hydroxide 91 00:05:26.326 --> 00:05:29.696 and the presence of glucose, which we will discuss in the later slide. 92 00:05:30.229 --> 00:05:33.032 And this is all part of the diagnostic criteria. 93 00:05:34.667 --> 00:05:36.002 Most patients are 94 00:05:36.002 --> 00:05:39.839 asymptomatic, or some may complain of some mild discomfort 95 00:05:39.839 --> 00:05:42.842 due to the vaginal discharge and irritation. 96 00:05:44.477 --> 00:05:44.844 And there's 97 00:05:44.844 --> 00:05:49.015 several risk factors associated with increased bacterial vaginosis, 98 00:05:49.549 --> 00:05:52.552 such as sexual intercourse with multiple or new partners 99 00:05:53.019 --> 00:05:57.123 in utero and device use, recent antibiotic use, etc. 100 00:05:57.790 --> 00:05:59.792 although BV is not considered an STI, 101 00:05:59.792 --> 00:06:02.795 it is more common in sexually active individuals. 102 00:06:03.663 --> 00:06:07.633 So with that, the 2021 CDC treatment guidelines recommend that all women 103 00:06:07.800 --> 00:06:12.672 bacterial vaginosis should be tested for HIV and other STIs, as well. 104 00:06:13.740 --> 00:06:16.909 So what are the factors involved in the pathogenesis 105 00:06:16.909 --> 00:06:19.912 of bacterial vaginosis 106 00:06:19.912 --> 00:06:21.414 in the vagina microbiome? 107 00:06:21.414 --> 00:06:24.617 There are hydrogen peroxide producing lactobacilli, 108 00:06:24.884 --> 00:06:28.988 which appear to be important in preventing overgrowth of anaerobes 109 00:06:29.222 --> 00:06:34.160 that are normally present in the vagina microbiota, and they do this by producing 110 00:06:34.160 --> 00:06:39.465 lactic acid and H2o2, which keeps this anaerobic bacteria in check. 111 00:06:41.501 --> 00:06:42.368 With the loss of 112 00:06:42.368 --> 00:06:46.172 lactobacilli, there is increase 113 00:06:46.472 --> 00:06:49.475 and the massive overgrowth of vaginal anaerobes occurs. 114 00:06:50.042 --> 00:06:52.412 Some bacterial vaginosis can be thought of 115 00:06:52.412 --> 00:06:55.214 as a disturbance in the vaginal ecosystem. 116 00:06:55.214 --> 00:06:58.885 The current understanding of the pathogenesis of bacteria vaginosis 117 00:06:59.118 --> 00:07:03.022 suggests a loss of the normal and highly beneficial lactobacilli flora, 118 00:07:03.356 --> 00:07:07.693 and the overgrowth of the commensal anaerobic bacteria, resulting in a state 119 00:07:07.693 --> 00:07:10.696 of what is called vaginal dysbiosis. 120 00:07:11.464 --> 00:07:15.501 These anaerobes produce large amounts of proteolytic coupled 121 00:07:15.601 --> 00:07:20.239 Solis enzymes, which break down vaginal peptides into a variety of amines 122 00:07:20.373 --> 00:07:24.510 that are volatile, malodorous, and associated with increased vaso 123 00:07:24.510 --> 00:07:28.047 secretion and squamous epithelial cell exfoliation, 124 00:07:28.448 --> 00:07:32.985 resulting in the typical clinical features that we see in patients with BV. 125 00:07:33.986 --> 00:07:38.124 And the reason also facilitates adherence of BV 126 00:07:38.124 --> 00:07:42.128 causing organisms such as GA nella to the epithelial cells. 127 00:07:45.832 --> 00:07:46.699 Recent vaginal 128 00:07:46.699 --> 00:07:51.737 microbiome studies have shown that BV is not a one organism syndrome, 129 00:07:51.737 --> 00:07:55.641 rather than an imbalance involving multiple species of bacteria. 130 00:07:56.642 --> 00:07:59.879 The microbiology of BV can be quite heterogeneous, 131 00:08:00.279 --> 00:08:04.150 and this figure, from a 2013 study analyzing the visual microbiota 132 00:08:04.150 --> 00:08:08.921 of about 163 women, demonstrated that Lactobacillus species, 133 00:08:09.188 --> 00:08:13.493 especially Lactobacillus innis and Crispus, were predominant 134 00:08:13.493 --> 00:08:16.496 in healthy women who served as controls for the study. 135 00:08:18.197 --> 00:08:20.433 These women also had organisms 136 00:08:20.433 --> 00:08:24.470 that caused bacterial vaginosis, but more so in fewer amounts 137 00:08:26.172 --> 00:08:27.607 relative to the healthy women. 138 00:08:27.607 --> 00:08:31.611 Women with bacterial vaginosis had significantly higher loads 139 00:08:31.611 --> 00:08:32.912 of bacterial vaginosis. 140 00:08:32.912 --> 00:08:35.948 Associated bacteria such as Gardner lavage. 141 00:08:35.948 --> 00:08:37.650 Now this is a problem. 142 00:08:37.650 --> 00:08:41.921 Virginia Nagas fear a predator, and these were all detected 143 00:08:41.954 --> 00:08:46.325 above the threshold and are highly predictive of bacterial vaginosis. 144 00:08:49.295 --> 00:08:50.696 Cardinal, which is the key 145 00:08:50.696 --> 00:08:54.600 pathogen and likely sexually transmitted, infects 146 00:08:54.600 --> 00:08:58.170 the viral epithelium and alters the virginal environment 147 00:08:58.671 --> 00:09:02.275 in such a way that it displaces the protective lactobacilli. 148 00:09:03.509 --> 00:09:07.547 The overgrowth of this anaerobic bacterium, which is unfavorable 149 00:09:07.547 --> 00:09:12.118 to the normal hydrogen peroxide producing Lactobacillus, elevates the vagina. 150 00:09:12.118 --> 00:09:15.955 PH and produces metabolites like vaginal 151 00:09:16.756 --> 00:09:19.759 by the taste that further on promotes 152 00:09:19.825 --> 00:09:24.931 breakdown of the protective mucosal layer on the vaginal epithelium, 153 00:09:24.931 --> 00:09:29.635 causing increased adherence of BV associate bacteria such as ITA. 154 00:09:29.635 --> 00:09:33.606 Problem prevalent along the vaginal epithelium, 155 00:09:33.606 --> 00:09:39.812 leading to the formation of a poly microbial bacterial vaginosis biofilm CI. 156 00:09:39.812 --> 00:09:43.049 The disease is known to facilitate the destruction of this protective 157 00:09:43.049 --> 00:09:46.752 mucus layer on the virgin epithelium, and this process 158 00:09:47.019 --> 00:09:51.691 possibly facilitates addition of bacterial cells on the epithelium 159 00:09:52.091 --> 00:09:56.262 and is linked with the development of the biofilm and pathogenic conditions. 160 00:10:01.667 --> 00:10:04.770 So there are certain complications that can be associated 161 00:10:04.770 --> 00:10:09.041 with bacteria vaginosis when it goes undetected. 162 00:10:09.041 --> 00:10:13.579 An undiagnosed and untreated there's a high risk for preterm delivery. 163 00:10:13.879 --> 00:10:17.583 Premature rupture of membranes in pregnant women, there's increased 164 00:10:17.583 --> 00:10:21.887 risk of pelvic inflammatory disease, CV is also known 165 00:10:22.121 --> 00:10:25.825 to increase the susceptibility to HIV infection and transmission 166 00:10:26.192 --> 00:10:29.595 and acquisition of other STI, such as chlamydia and gonorrhea. 167 00:10:30.262 --> 00:10:34.667 There's persistence of HPV infection and progression of cervical lesions, 168 00:10:34.967 --> 00:10:38.971 possibly leading to cervical cancer, and the recurring rate 169 00:10:38.971 --> 00:10:42.541 is about 25% within 4 to 6 weeks after treatment. 170 00:10:43.042 --> 00:10:46.112 So it's highly important to diagnose DV accurately 171 00:10:46.112 --> 00:10:49.115 for patient management and. 172 00:10:50.016 --> 00:10:53.486 There are several diagnostic approaches for bacterial vaginosis. 173 00:10:53.686 --> 00:10:55.921 And these can range from traditional methods 174 00:10:55.921 --> 00:10:59.492 such as the vaginal gram stain with the Nugent score 175 00:10:59.792 --> 00:11:02.762 to point of care assays in the clinic setting, 176 00:11:02.762 --> 00:11:06.465 and to advanced molecular assays with nucleic acid amplification 177 00:11:06.465 --> 00:11:07.767 in the clinical laboratories. 178 00:11:09.869 --> 00:11:12.672 The traditional gold standard for diagnosing natural 179 00:11:12.672 --> 00:11:16.709 vaginosis is a vaginal graph stain with Nugent score determination, 180 00:11:17.243 --> 00:11:20.179 and this is based on the relative concentration 181 00:11:20.179 --> 00:11:23.182 of the good bacteria, which is the lactobacillus. 182 00:11:23.382 --> 00:11:27.486 Compared to the anaerobic gardener and mobile monkeys species. 183 00:11:28.487 --> 00:11:31.223 In this method, the value gram seen is assessed 184 00:11:31.223 --> 00:11:34.960 for the presence of large gram positive rods of Lactobacillus. 185 00:11:35.294 --> 00:11:38.431 Small gram variable rods of cardinals, and the curved 186 00:11:38.431 --> 00:11:41.400 gram variable rods of mobile monkeys. 187 00:11:41.500 --> 00:11:47.206 The sensitivity of this is about 89%, with a specificity of 83%, 188 00:11:47.707 --> 00:11:51.577 and this method can be pretty time consuming and needs trained 189 00:11:51.711 --> 00:11:54.714 microscopist in the hospital setting. 190 00:11:56.282 --> 00:11:58.751 So how is the scoring determined? 191 00:11:58.751 --> 00:12:01.754 A score of 0 to 3 is consistent 192 00:12:01.854 --> 00:12:07.159 with a normal vaginal flora, and is negative for bacterial vaginosis. 193 00:12:07.193 --> 00:12:12.531 As you can see, you can only detect the gram positive lactobacilli rods. 194 00:12:13.499 --> 00:12:16.302 A score of 4 to 6 is consistent 195 00:12:16.302 --> 00:12:21.107 with an immediate or an altered flora, but then emergence of GA nella. 196 00:12:21.107 --> 00:12:24.143 As you can see, different Warford types in this image, 197 00:12:25.244 --> 00:12:29.548 and a score of 7 to 10 is indicative of bacterial vaginosis, 198 00:12:30.282 --> 00:12:33.853 with lack of the gram positive lactobacilli 199 00:12:34.253 --> 00:12:39.125 and emergence of the gram negative cultured bacilli indicating GA nlm. 200 00:12:39.558 --> 00:12:39.992 So here 201 00:12:39.992 --> 00:12:44.830 you can see the changes in the ground, see morphology from a normal vaginal flora 202 00:12:44.830 --> 00:12:49.201 with predominantly Lactobacillus to the intermediate or altered flora. 203 00:12:49.535 --> 00:12:53.472 But you lose the lactobacilli and then see more of the garden yellow 204 00:12:54.006 --> 00:12:57.676 then progressing to BV where you hardly find any lactobacilli, 205 00:12:57.676 --> 00:13:00.679 but tons of other more food types. 206 00:13:02.515 --> 00:13:04.183 For bacterial vaginosis 207 00:13:04.183 --> 00:13:08.521 microscopy with the Amsler criteria has been commonly used in the clinic. 208 00:13:08.521 --> 00:13:10.489 A point of care setting, 209 00:13:10.489 --> 00:13:13.993 and in this criteria the presence of three of the following 210 00:13:13.993 --> 00:13:18.097 four criteria provides sufficient evidence for a clinical diagnosis 211 00:13:18.097 --> 00:13:19.532 of bacterial vaginosis, 212 00:13:20.533 --> 00:13:20.933 and this 213 00:13:20.933 --> 00:13:23.936 include a thin homogeneous discharge, 214 00:13:24.170 --> 00:13:27.606 the presence of more than 20% of CLU cells, 215 00:13:27.840 --> 00:13:32.611 or high power field, a vaginal pH of more than 4.5, 216 00:13:33.112 --> 00:13:35.648 and a positive whiff test for the presence 217 00:13:35.648 --> 00:13:38.651 of a fishy amine odor. 218 00:13:38.684 --> 00:13:42.655 Three of the four two criteria are needed to make a diagnosis. 219 00:13:43.355 --> 00:13:48.961 The sensitivity of this is about 37 to 70%, with a specificity of about 220 00:13:48.961 --> 00:13:53.432 94 to 99%, respectively, compared to the gold standard grandstand 221 00:13:53.432 --> 00:13:57.036 mutant score, and this has some moderate reproducibility 222 00:13:57.036 --> 00:14:00.039 as well. 223 00:14:01.440 --> 00:14:04.410 This image shows the presence of a clue cell, 224 00:14:04.510 --> 00:14:09.081 which are bacteria that are clumping the vaginal epithelial cell 225 00:14:09.114 --> 00:14:13.886 and obscuring the border, as seen in this image on a ceiling. 226 00:14:13.886 --> 00:14:16.889 Wet preparation. 227 00:14:20.259 --> 00:14:21.260 Other point of care 228 00:14:21.260 --> 00:14:24.663 EBV assays include the awesome BV blue test, 229 00:14:25.264 --> 00:14:29.501 and this is a clear wave point of care test that detects vaginal 230 00:14:29.501 --> 00:14:32.805 solids activity produced by garden color, vaginal 231 00:14:33.405 --> 00:14:36.408 privateer, Bacteroides, etc. 232 00:14:36.775 --> 00:14:40.679 this usually results in about ten minutes and has a pretty good sensitivity, 233 00:14:40.679 --> 00:14:45.584 about 92%, with a specificity of 98% compared to the Nugent score. 234 00:14:46.318 --> 00:14:51.357 However, this does not detect other causes of genetics or rules out other STIs. 235 00:14:53.759 --> 00:14:54.593 So let's 236 00:14:54.593 --> 00:14:59.598 switch gears a bit and move into the next most common cause of virgin itis, 237 00:14:59.899 --> 00:15:02.902 which is Candida. 238 00:15:03.802 --> 00:15:04.837 Commonly referred to 239 00:15:04.837 --> 00:15:09.308 as a yeast infection, Candida vaginas is caused by abnormal overgrowth 240 00:15:09.308 --> 00:15:12.344 of one or more Canada species in the vaginal tract. 241 00:15:13.412 --> 00:15:17.850 Some amount of Canada is typically found in healthy vaginal flora, 242 00:15:18.317 --> 00:15:22.187 so it's important to identify clinically significant levels for infection. 243 00:15:23.555 --> 00:15:28.460 In the US, about 13 million cases of Canada virgin itis or vulgar 244 00:15:28.460 --> 00:15:33.299 vaginal candidiasis are seen, but they often go underreported 245 00:15:33.732 --> 00:15:36.535 as women can be either asymptomatic or often 246 00:15:36.535 --> 00:15:39.538 are self-diagnosed. 247 00:15:40.039 --> 00:15:40.806 Candida vaginas. 248 00:15:40.806 --> 00:15:46.011 This is so common after BVI that 75% of women in their lifetime 249 00:15:46.445 --> 00:15:51.183 at least have one occurrence, with about 50% having a reoccurrence. 250 00:15:52.051 --> 00:15:55.654 Some of the risk factors include hormonal changes, diabetes, 251 00:15:55.654 --> 00:16:00.259 pregnancy, use of antibiotics or steroids or HIV infection. 252 00:16:01.560 --> 00:16:02.261 One important 253 00:16:02.261 --> 00:16:05.264 point is that Canada is not sexually transmitted, 254 00:16:06.165 --> 00:16:08.701 as Canada species are generally considered 255 00:16:08.701 --> 00:16:11.670 normal flora of the vaginal microbiome. 256 00:16:11.837 --> 00:16:14.807 However, disruption of the vast microbiome 257 00:16:14.807 --> 00:16:18.043 can switch the role of Canada from a commensal to a pathogen. 258 00:16:19.044 --> 00:16:22.681 In these instances, Candida albicans is the most prevalent species 259 00:16:22.915 --> 00:16:27.353 and is responsible for about up to 90% of cases of Candida vaccinators. 260 00:16:28.387 --> 00:16:31.390 Other non other constraints like Canada, the broader 261 00:16:31.890 --> 00:16:34.393 which the second most prevalent Candida species 262 00:16:34.393 --> 00:16:38.831 can be associated with recurrent disease, possibly due to Aids or resistance, 263 00:16:38.831 --> 00:16:41.834 which are usually the drugs of choice for treating Candida. 264 00:16:42.968 --> 00:16:45.571 Candida Virginia is often overdiagnosed 265 00:16:45.571 --> 00:16:48.574 in prepubescent post-menopausal individuals, 266 00:16:49.341 --> 00:16:53.278 and it's really not clear why some women may develop symptoms, 267 00:16:53.278 --> 00:16:56.281 while others may remain asymptomatic, 268 00:16:56.281 --> 00:16:58.517 and many patients self-diagnose 269 00:16:58.517 --> 00:17:02.421 and use over-the-counter treatment only to have reoccurrence in the future. 270 00:17:03.389 --> 00:17:03.989 And unlike 271 00:17:03.989 --> 00:17:08.660 bacterial vaginosis, Candida vaginas is generally not associated 272 00:17:08.660 --> 00:17:11.663 with any change in vaginal lactobacilli. 273 00:17:15.768 --> 00:17:17.436 The clinical features of Canada. 274 00:17:17.436 --> 00:17:22.307 But genetics can include multiple symptoms such as burning, itching, soreness, 275 00:17:22.641 --> 00:17:27.679 and in some instances, vaginal discharge, which can be described as either cheesy 276 00:17:27.679 --> 00:17:32.918 or cold like with clumpy appearance, and can be white or even and odorless. 277 00:17:33.685 --> 00:17:36.855 The individual with Canada vaginas can complain of vulva 278 00:17:36.855 --> 00:17:40.926 burning or itching with some redness as well, and dysphoria 279 00:17:40.926 --> 00:17:44.063 may be the only complaint in these individuals. 280 00:17:44.897 --> 00:17:48.167 In some patients, there can be pain with sexual intercourse, 281 00:17:48.534 --> 00:17:52.137 or they can be a flare prior to the onset of menses. 282 00:17:54.440 --> 00:17:57.009 For a diagnosis of verbal vaginal candidiasis, 283 00:17:57.009 --> 00:18:01.246 the most common method is the wet mound microscopy in the clinic setting, 284 00:18:01.680 --> 00:18:05.217 and this is done to visualize budding yeast or harmful forms. 285 00:18:05.851 --> 00:18:09.555 This can be done using saline or potassium hydroxide, 286 00:18:09.822 --> 00:18:13.392 which makes it easier to visualize fungal elements such as pseudo hyphae. 287 00:18:15.394 --> 00:18:17.262 In these patients, the of 288 00:18:17.262 --> 00:18:20.766 is typically normal, so it's about less than 4.5. 289 00:18:22.267 --> 00:18:27.206 And if the pH is abnormally high, this can suggest an alternative diagnosis 290 00:18:27.206 --> 00:18:30.342 of actual vaginosis to come analysis, or perhaps 291 00:18:30.342 --> 00:18:33.345 of mixed vaginal infection. 292 00:18:33.612 --> 00:18:36.915 The sensitivity of Westmount tends to be quite low, 293 00:18:37.483 --> 00:18:40.919 and it's about 43 to 78%, 294 00:18:40.919 --> 00:18:44.189 with a specificity of 75 to 88%. 295 00:18:47.493 --> 00:18:48.760 Fungal culture remains 296 00:18:48.760 --> 00:18:52.464 the gold standard diagnostic that can identify multiple Candida species 297 00:18:52.798 --> 00:18:56.235 and can be used for Vegemite is that is persistent or recurrent, 298 00:18:56.768 --> 00:19:01.206 and is helpful to identify Asal resistant strains of Candida, as well. 299 00:19:02.341 --> 00:19:05.310 In women with complicated viable vaginal candidiasis, 300 00:19:05.310 --> 00:19:08.347 fungal cultures are indicated to confirm the diagnosis 301 00:19:08.847 --> 00:19:12.784 and to detect noncombatant species and that is particularly important 302 00:19:12.784 --> 00:19:14.319 for identifying Canada 303 00:19:14.319 --> 00:19:18.690 Labrador, Canada scruci, since these could be missed on microscopic. 304 00:19:21.860 --> 00:19:23.562 The last pathogen we will discuss 305 00:19:23.562 --> 00:19:27.032 today is the motile protozoan triggerman Aspergillus, 306 00:19:27.599 --> 00:19:30.903 and this is one of my favorite star causing organisms. 307 00:19:32.371 --> 00:19:34.873 Chukerman is vaginal is the cause of chukerman. 308 00:19:34.873 --> 00:19:37.943 ISIS is the most common curable STI 309 00:19:38.677 --> 00:19:42.014 and humans are the only host of this pathogen. 310 00:19:42.948 --> 00:19:46.251 It is known to cause vaccinators, service status 311 00:19:46.752 --> 00:19:49.755 and pelvic inflammatory disease in women. 312 00:19:50.055 --> 00:19:53.058 Men are often asymptomatic. 313 00:19:53.759 --> 00:19:56.161 Tick A modest vaginal is a motile sludge. 314 00:19:56.161 --> 00:20:00.132 Later, protozoan with the trough was a wide stage and undergoes 315 00:20:00.132 --> 00:20:05.237 replication by longitudinal binary fission in the lower gentle tract, 316 00:20:05.737 --> 00:20:08.740 and this way can persist for long periods of time. 317 00:20:11.009 --> 00:20:12.477 Chukerman homeowners TV 318 00:20:12.477 --> 00:20:16.148 or track is one of the most common curable SIDs in the United States, 319 00:20:16.982 --> 00:20:19.952 with an estimated prevalence of 2.6 million. 320 00:20:20.385 --> 00:20:23.088 It's very similar to or higher than chlamydia. 321 00:20:23.088 --> 00:20:26.458 Trachoma is, but it is not a reportable disease. 322 00:20:26.592 --> 00:20:28.393 And unlike chlamydia and gonorrhea, 323 00:20:28.393 --> 00:20:31.530 there are no screening recommendations for the general population. 324 00:20:32.431 --> 00:20:36.702 So the race of track or TV may be higher than this estimated prevalence. 325 00:20:40.005 --> 00:20:43.375 In contrast to chlamydia and gonorrhea, which have high rates in women younger 326 00:20:43.375 --> 00:20:47.646 than 25 years of age, the estimated prevalence of the commonest 327 00:20:47.646 --> 00:20:51.283 vaginal is tends to be uniform across a wide range of ages, 328 00:20:51.617 --> 00:20:54.620 with the highest detection in women 329 00:20:54.820 --> 00:20:57.689 aged 45 to 55 years. 330 00:20:57.689 --> 00:21:01.526 One such reason as noted by a study by Stemmer at all, 331 00:21:02.194 --> 00:21:07.432 said that it could be due to the commonest buzzing levels infiltrating susceptible 332 00:21:07.432 --> 00:21:10.836 glands being detected only during hormonal or antibiotic 333 00:21:10.836 --> 00:21:13.839 induced changes in the virginal flora. 334 00:21:14.339 --> 00:21:18.076 Other studies have speculated that this could also be due to the fact that 335 00:21:18.076 --> 00:21:21.480 since there are no screening guidelines for TV in the general population, 336 00:21:21.913 --> 00:21:25.550 TB is not getting detected or treated and is persisting year 337 00:21:25.550 --> 00:21:28.553 after year. 338 00:21:29.788 --> 00:21:30.756 Majority of women 339 00:21:30.756 --> 00:21:33.759 with infections are asymptomatic. 340 00:21:33.859 --> 00:21:37.029 The 20% that do have symptoms may present 341 00:21:37.296 --> 00:21:42.100 with some malodorous discharge that can be frothy or purulent. 342 00:21:42.768 --> 00:21:45.771 Women could also have a burning itching sensation, 343 00:21:45.937 --> 00:21:48.940 increase urination, painful intercourse. 344 00:21:49.374 --> 00:21:52.144 They can have complaints of lower abdominal pain 345 00:21:52.144 --> 00:21:54.946 with the erythema of the vulva and basilar mucosa. 346 00:21:56.348 --> 00:21:59.251 In some individuals, punctured hemorrhages 347 00:21:59.251 --> 00:22:02.688 may be visible on the vaso mucosa or cervix. 348 00:22:03.121 --> 00:22:06.491 This is commonly called as a strawberry cervix, as it resembles 349 00:22:06.725 --> 00:22:09.895 a strawberry with the pink date epithelial layer. 350 00:22:14.333 --> 00:22:17.069 So what are the indications for testing which are common? 351 00:22:17.069 --> 00:22:20.939 Again, since there are no screening recommendations, women 352 00:22:20.939 --> 00:22:23.675 there are seeking care for vaginal discharge. 353 00:22:23.675 --> 00:22:27.245 Those that have had a high risk of infection that includes 354 00:22:27.279 --> 00:22:30.582 new or multiple partners, a history of STDs. 355 00:22:31.049 --> 00:22:36.288 They are commercial sex workers and also women that are pregnant 356 00:22:36.288 --> 00:22:39.758 and are at high risk for acquiring these sexually transmitted diseases 357 00:22:40.125 --> 00:22:43.128 can be tested for chukerman as vaginally. 358 00:22:43.862 --> 00:22:46.198 If left untreated, there are severe 359 00:22:46.198 --> 00:22:49.201 consequences for trachoma analysis 360 00:22:49.501 --> 00:22:53.071 and again, as mentioned earlier, these could be acquisition 361 00:22:53.071 --> 00:22:57.008 of other sources such as chlamydia, gonorrhea, HSV two. 362 00:22:57.476 --> 00:23:00.946 There's increased time to clear HPV infections. 363 00:23:01.913 --> 00:23:02.881 There is 364 00:23:02.881 --> 00:23:07.919 also a connection with chick analysis and pre-term birth and low birth 365 00:23:07.919 --> 00:23:12.724 weight in pregnant women, and also pelvic inflammatory disease. 366 00:23:12.724 --> 00:23:15.727 And there's an increased risk of endometriosis. 367 00:23:17.062 --> 00:23:20.065 So how do you diagnose homeowners. 368 00:23:20.132 --> 00:23:23.568 And this can be done by traditional methods, 369 00:23:23.769 --> 00:23:28.974 using a point of care by wet prep microscopy of vaginal swabs. 370 00:23:29.341 --> 00:23:32.144 And this test, however, must be performed in 10 371 00:23:32.144 --> 00:23:35.147 to 20 minutes after the specimen is collected. 372 00:23:35.280 --> 00:23:37.649 Otherwise, the homeowners can lose viability 373 00:23:37.649 --> 00:23:40.652 and the sensitivity can drop to 20%. 374 00:23:41.553 --> 00:23:43.455 The diagnosis can be confirmed 375 00:23:43.455 --> 00:23:46.458 when necessary, with culture 376 00:23:47.092 --> 00:23:48.360 invasion of specimens. 377 00:23:48.360 --> 00:23:53.498 The Westmount sensitivity is quite low, about 44 to 68%, 378 00:23:53.865 --> 00:23:55.734 but it has high specificity. 379 00:23:55.734 --> 00:23:59.704 As long as you're able to detect that motile chukerman out in the wet prep. 380 00:24:03.308 --> 00:24:03.942 Culture can be 381 00:24:03.942 --> 00:24:07.145 more sensitive than the wet mound, but it's not widely available. 382 00:24:07.813 --> 00:24:10.949 There are various kits, such as in pulse system 383 00:24:10.949 --> 00:24:15.487 or the diamonds medium, that are used to culture to commodes, 384 00:24:15.821 --> 00:24:19.458 and this was considered the most sensitive method for diagnosing 385 00:24:19.791 --> 00:24:22.461 chook homeowners before molecular detection 386 00:24:22.461 --> 00:24:25.464 methods became available. 387 00:24:25.730 --> 00:24:27.866 Culture has a sensitivity of about 388 00:24:27.866 --> 00:24:32.337 44 to 75%, and the specificity of about 100%, 389 00:24:33.071 --> 00:24:36.842 and in women, vaso secretions are the preferred specimen type 390 00:24:36.842 --> 00:24:39.811 for culture because urine can be very less sensitive. 391 00:24:41.179 --> 00:24:45.417 This method can take a few days as the in pouch specimen 392 00:24:45.417 --> 00:24:48.420 or the diamond's medium needs to be examined daily 393 00:24:48.653 --> 00:24:52.491 with the use of a microscope for two minutes for five days 394 00:24:52.491 --> 00:24:56.761 over a seven day period to reduce the possibility of any false negatives. 395 00:24:57.963 --> 00:24:58.797 And one of the biggest 396 00:24:58.797 --> 00:25:02.634 advantages of culture is in the setting of drug resistance testing. 397 00:25:02.634 --> 00:25:03.935 What you need to see 398 00:25:03.935 --> 00:25:06.938 when the patient's coming back for recurrent trachoma analysis, 399 00:25:07.272 --> 00:25:10.909 if they are resistant to the other waste treatment regimens 400 00:25:10.909 --> 00:25:13.912 that are available. 401 00:25:15.046 --> 00:25:16.882 There are FDA cleared 402 00:25:16.882 --> 00:25:20.218 or clear waived point of care tests for vaginal specimens. 403 00:25:20.218 --> 00:25:23.221 And this is the awesome to commonest rapid test, 404 00:25:23.522 --> 00:25:27.092 which is an antigen detection test that uses immuno 405 00:25:27.092 --> 00:25:31.863 chromatographic capillary flow dipstick technology and can be performed 406 00:25:31.863 --> 00:25:36.201 at the clinic using visual specimens within 10 to 15 minutes. 407 00:25:37.102 --> 00:25:39.371 The sensitivity of this test ranges 408 00:25:39.371 --> 00:25:43.341 from about 82 to 95%, with the specificity of 97 409 00:25:43.341 --> 00:25:46.311 to 100% compared to wet Westmount culture, 410 00:25:46.545 --> 00:25:49.548 and not testing. 411 00:25:50.181 --> 00:25:52.317 A study of about 209 women 412 00:25:52.317 --> 00:25:56.254 reported that more than 99% could correctly perform and interpret 413 00:25:56.254 --> 00:25:59.257 a visual self-test by using the awesome assay. 414 00:25:59.925 --> 00:26:04.829 However, this is not approved for diagnosing Teichmann as vaginal less in men. 415 00:26:08.133 --> 00:26:08.433 Over the 416 00:26:08.433 --> 00:26:12.537 past decade, there have been multiple knots that have come to the market 417 00:26:12.537 --> 00:26:15.540 that have replaced culture as the gold standard. 418 00:26:16.241 --> 00:26:19.678 CDC now recommends not testing for women 419 00:26:19.678 --> 00:26:22.714 seeking care for vaginal discharge due to Czech homeowners. 420 00:26:22.714 --> 00:26:24.349 Vaginal 421 00:26:24.349 --> 00:26:27.385 and that are highly sensitive, detecting more Czech 422 00:26:27.552 --> 00:26:31.189 in vaginas, infections and ratman microscopy among women. 423 00:26:32.357 --> 00:26:37.429 Here is a list of the more common, commercially available FDA cleared assays 424 00:26:37.429 --> 00:26:40.432 that have high sensitivity and specificity, 425 00:26:40.732 --> 00:26:43.735 ranging from 95% to 100%. 426 00:26:44.235 --> 00:26:46.338 These are cleared for use in women 427 00:26:46.338 --> 00:26:49.341 for vaginal, urine and cervical swabs. 428 00:26:49.741 --> 00:26:52.377 Some are approved for men, but for only or 429 00:26:52.377 --> 00:26:55.380 urine specimens. 430 00:26:56.047 --> 00:26:58.016 Moving on to the broader molecular 431 00:26:58.016 --> 00:27:01.019 diagnosis of virgin iris, 432 00:27:01.920 --> 00:27:05.557 this is a relatively new area for Virginia. 433 00:27:05.557 --> 00:27:08.560 It is diagnostics because virginity 434 00:27:08.627 --> 00:27:11.630 is a global term for a nonspecific syndrome, 435 00:27:11.796 --> 00:27:15.634 and because the condition has three distinct etiologies 436 00:27:15.634 --> 00:27:20.205 or the common ones, such as BV Canada, virgin Itis, and took homeowners. 437 00:27:21.206 --> 00:27:24.209 It's important to have accurate differential diagnosis 438 00:27:24.209 --> 00:27:28.880 for effective treatment and to avoid the risk of diagnosis. 439 00:27:29.781 --> 00:27:32.784 Clinicians therefore cannot rely on symptoms alone 440 00:27:32.851 --> 00:27:36.287 to distinguish confidently between these different causes of virgin. 441 00:27:36.287 --> 00:27:38.790 Itis. 442 00:27:38.790 --> 00:27:40.759 Traditional lapidary methods such as grams, 443 00:27:40.759 --> 00:27:43.862 stain and culture are available in some scenarios, 444 00:27:43.862 --> 00:27:47.432 but they are highly subjective to sampling transport conditions, 445 00:27:47.899 --> 00:27:51.569 technical proficiencies, and may have prolonged turnaround times. 446 00:27:52.971 --> 00:27:56.808 Traditional in clinic diagnostic methods can often lead to inaccurate, 447 00:27:56.808 --> 00:28:00.145 incomplete diagnosis and in some cases, high recurrence rate. 448 00:28:02.347 --> 00:28:05.717 Molecular diagnostic methods using nucleic acid testing, 449 00:28:05.717 --> 00:28:09.954 or knots are now the new generation of laboratory tools for vaccinators. 450 00:28:09.954 --> 00:28:11.556 Diagnosis. 451 00:28:11.556 --> 00:28:14.926 Night testing with multiplexing capability 452 00:28:15.260 --> 00:28:19.497 allow for multiple detection of targets so you can detect B.V. 453 00:28:19.531 --> 00:28:22.500 Canada and homeowners all in one sample. 454 00:28:22.901 --> 00:28:25.270 Knots are advantages over traditional methods, 455 00:28:25.270 --> 00:28:29.708 since they do not require any microscopy or any other point of care procedures, 456 00:28:30.308 --> 00:28:33.878 and in the same vaginal swab can be used to detect other 457 00:28:33.978 --> 00:28:36.981 STI such as chlamydia, gonorrhea and these are 458 00:28:37.115 --> 00:28:40.719 those that are either collected by the clinician or are self collected. 459 00:28:44.589 --> 00:28:45.557 Point of care molecular 460 00:28:45.557 --> 00:28:48.593 probes as they can be used for diagnosing virgin itis. 461 00:28:49.327 --> 00:28:51.996 This molecular assay, known as the affirm 462 00:28:51.996 --> 00:28:57.635 v3 assay, uses a DNA hybridization probe that can detect high concentrations 463 00:28:57.635 --> 00:29:00.638 of cardinal vaginal, and can also detect 464 00:29:00.872 --> 00:29:03.842 Czech homeowners and Canada albicans. 465 00:29:04.142 --> 00:29:07.145 It requires its own individual collection device, 466 00:29:07.512 --> 00:29:10.548 and there's no target amplification prior to detection. 467 00:29:11.883 --> 00:29:14.519 It has been designed for use in the doctor's office 468 00:29:14.519 --> 00:29:17.522 or laboratory setting, but it's not clear why it 469 00:29:18.256 --> 00:29:22.327 when the direct probe assay is used alone to diagnose bacteria vaginosis. 470 00:29:22.327 --> 00:29:26.431 It has a low sensitivity and specificity when compared with gram, Stein 471 00:29:26.431 --> 00:29:28.166 and Nugent scoring. 472 00:29:28.166 --> 00:29:31.469 If, however, this test is used in conjunction with the vaginal 473 00:29:31.703 --> 00:29:35.774 pH measurement and presence of amine odor, the test performance improves 474 00:29:35.774 --> 00:29:40.111 with a sensitivity of about 94% and specificity of 81%. 475 00:29:40.879 --> 00:29:44.282 One limitation is that the AC only detects Gardella vaginal 476 00:29:44.916 --> 00:29:49.487 and not other organisms, and we know that BV is a multi organism 477 00:29:49.487 --> 00:29:52.557 syndrome, so detection of only a single organism 478 00:29:52.557 --> 00:29:55.293 may not provide us with an accurate or complete picture. 479 00:29:56.895 --> 00:30:00.098 For Tucuman as vaginally the sensitivity is reduced 480 00:30:00.098 --> 00:30:03.368 compared to direct nucleic acid amplification testing. 481 00:30:05.303 --> 00:30:08.907 There are now multiple FDA cleared Virginias assay 482 00:30:08.907 --> 00:30:13.077 that are commercially available, and some that are offered as lab developed test. 483 00:30:13.077 --> 00:30:15.814 In the reference laboratories. 484 00:30:15.814 --> 00:30:17.882 These include PCR based 485 00:30:17.882 --> 00:30:20.852 or transcription mediated amplification based assays. 486 00:30:22.353 --> 00:30:26.324 These acids are multiplex, quantitative or semi quantitative assays 487 00:30:26.624 --> 00:30:30.662 that detect lactobacilli species and certain bacterial vaginosis 488 00:30:30.662 --> 00:30:34.432 associated bacteria such as Garden yellow or Prevotella. 489 00:30:34.899 --> 00:30:38.436 The associate bacteria can vary among these tests, 490 00:30:39.003 --> 00:30:42.006 as the exact etiology is still not very well understood. 491 00:30:43.608 --> 00:30:45.944 It is important to note that these should only be 492 00:30:45.944 --> 00:30:48.947 used in women with symptomatic infection. 493 00:30:50.048 --> 00:30:52.784 In this slide, I wanted to highlight some of the advantages 494 00:30:52.784 --> 00:30:55.787 of Nat testing over the traditional diagnostics 495 00:30:56.287 --> 00:31:00.225 Nat testing that generally objective and are able to differentially detect 496 00:31:00.391 --> 00:31:04.128 bacterial vaginosis through an algorithmic analysis 497 00:31:04.128 --> 00:31:07.599 of lactobacilli and bacteria involved in bacteria vaginosis, 498 00:31:09.100 --> 00:31:09.400 they can 499 00:31:09.400 --> 00:31:12.403 detect and differentiate between Canada species 500 00:31:12.537 --> 00:31:15.640 and separate those out with higher ISO resistance. 501 00:31:17.375 --> 00:31:21.446 They can be used on a self collected viral swab, and don't require 502 00:31:21.446 --> 00:31:25.316 the use of microscopy or the expertise necessary for accurate diagnosis. 503 00:31:26.851 --> 00:31:29.187 They show high sensitivity and specificity 504 00:31:29.187 --> 00:31:32.190 with good positive negative predictive values. 505 00:31:33.725 --> 00:31:38.029 However, traditional methods may still be useful due to the lower costs 506 00:31:38.029 --> 00:31:41.699 compared to the higher associated costs with molecular panels. 507 00:31:43.768 --> 00:31:45.603 So the last part of today's 508 00:31:45.603 --> 00:31:48.773 presentation, I want to focus a little bit about this 509 00:31:48.840 --> 00:31:51.843 and other issues that are associated with it. 510 00:31:53.745 --> 00:31:55.747 Recent published studies from Barbara 511 00:31:55.747 --> 00:31:58.750 van der Paul's group at the University of Alabama 512 00:31:58.816 --> 00:32:01.853 showed that 22% of women testing 513 00:32:01.853 --> 00:32:06.057 positive for vaginas, such as bacterial vaginosis or Candida species, 514 00:32:06.691 --> 00:32:11.462 were also infected with an STI, such as chlamydia and gonorrhea. 515 00:32:12.630 --> 00:32:13.464 Other data has 516 00:32:13.464 --> 00:32:17.435 shown that check homeowners vaginas often coexist with bachelor 517 00:32:17.468 --> 00:32:23.675 vaginosis, with a high Co detection rate of 60 to 80%, and approximately 518 00:32:23.675 --> 00:32:26.678 25% of women with bacterial vaginosis 519 00:32:27.178 --> 00:32:30.214 or Candida agitators also had an STI. 520 00:32:31.416 --> 00:32:36.387 With these data in consideration, the 2021 CDC Treatment Guidelines recommend 521 00:32:36.721 --> 00:32:40.291 that all women with bachelor doses should be tested for HIV 522 00:32:40.291 --> 00:32:43.294 and other STIs, as well. 523 00:32:44.162 --> 00:32:47.432 In this 2019 study of SCA detection rates, 524 00:32:47.432 --> 00:32:51.903 they saw that more than 80% of individuals positive for any STI, 525 00:32:51.903 --> 00:32:55.440 but also positive for back to a Vaginosis or Candida species, 526 00:32:56.341 --> 00:33:00.311 and women who were positive about vaginosis were significantly 527 00:33:00.578 --> 00:33:03.848 more likely to have an infection with chlamydia, 528 00:33:03.881 --> 00:33:06.884 or to commonness. 529 00:33:07.452 --> 00:33:10.421 And the study from this figure shows the distribution 530 00:33:10.421 --> 00:33:13.524 of sexually transmitted infection among women, but not Schneiders. 531 00:33:14.158 --> 00:33:18.363 And you can see that compared to the no Virgin Iris group, 532 00:33:19.330 --> 00:33:21.933 CTT was found to be detected. 533 00:33:21.933 --> 00:33:25.069 More individuals with BV or wouldbe with 534 00:33:25.069 --> 00:33:28.740 Candida compared to those without any vaginas. 535 00:33:28.740 --> 00:33:31.142 Diagnosis. 536 00:33:31.142 --> 00:33:34.112 Women with bacterial vaginosis alone 537 00:33:34.112 --> 00:33:38.883 or with concurrent Candida species infection had high rates of co-infection 538 00:33:38.883 --> 00:33:42.687 with other sexually transmitted infections such as kimonos, as well, 539 00:33:43.621 --> 00:33:45.857 so this data suggests that there is an increased 540 00:33:45.857 --> 00:33:50.261 risk of some STIs in women, while positive for BV or Candida, 541 00:33:50.795 --> 00:33:54.966 and thus provides a strong push for a more comprehensive testing 542 00:33:55.266 --> 00:33:58.269 for STIs. 543 00:33:59.537 --> 00:34:02.373 A more recent manuscript, published by Doctor 544 00:34:02.373 --> 00:34:06.411 Jane Schreck is Group highlighted a multicenter, cross-sectional study 545 00:34:06.878 --> 00:34:11.549 looking at two FDA cleared Nod assays for BV and vulva vaginal candidiasis, 546 00:34:12.183 --> 00:34:15.453 and the presence of other sites, including chlamydia, gonorrhea 547 00:34:15.453 --> 00:34:18.456 took homeowners and mycoplasma genitalia. 548 00:34:19.557 --> 00:34:21.325 This study included 21 U.S. 549 00:34:21.325 --> 00:34:24.562 sites with over 1000 women over the age of 14, 550 00:34:25.096 --> 00:34:28.533 and those that presented with symptoms of virgin itis either 551 00:34:28.533 --> 00:34:33.237 presenting to the ER, family medicine, ObGyn or varied STI clinics. 552 00:34:34.172 --> 00:34:35.940 The women were evaluated 553 00:34:35.940 --> 00:34:41.446 for bacteria vaginosis with a gram stain for Nugent Scoring and Amstel criteria 554 00:34:41.679 --> 00:34:45.750 for Canada by Culture and for Czech homeowners by culture and not testing. 555 00:34:47.585 --> 00:34:51.823 So about two thirds of these patients were seen to be positive 556 00:34:51.823 --> 00:34:56.661 for bacterial vaginosis, Czech homeowners or Canada vaginal is. 557 00:34:57.095 --> 00:35:01.532 And what third of them were negative for all three major players about tinnitus. 558 00:35:02.433 --> 00:35:07.071 Approximately 36% of these individuals were positive for EBV alone, 559 00:35:07.638 --> 00:35:12.076 16 for yeast and 2% for Czech homeowners. 560 00:35:12.510 --> 00:35:16.614 But a substantial number of individuals were also positive for mixed infections, 561 00:35:17.115 --> 00:35:20.351 either BV and trick or BV, and Candida. 562 00:35:21.853 --> 00:35:22.487 In this study. 563 00:35:22.487 --> 00:35:26.224 They then looked at the rates of STIs in the same patient cohort 564 00:35:26.624 --> 00:35:31.262 and found that about 45% of women with Bebe also had an STD, 565 00:35:31.462 --> 00:35:35.533 such as took monas, chlamydia or Mycoplasma genitalia. 566 00:35:37.435 --> 00:35:40.338 In this figure, they looked at bv positive women, 567 00:35:40.338 --> 00:35:46.244 with an N of five and 18 samples and bv negative women with an N of 533. 568 00:35:46.244 --> 00:35:52.083 By not testing about 26% of women that were positive for BV, 569 00:35:52.583 --> 00:35:57.054 but also positive for an STI, compared to 11.1% that were negative for BD. 570 00:35:57.989 --> 00:36:02.793 They also noted that CTV and MG rates were increased 571 00:36:02.793 --> 00:36:05.897 at least 2 to 3 fold in individuals with BV, 572 00:36:06.597 --> 00:36:08.332 and there were few cases of gonorrhea, 573 00:36:08.332 --> 00:36:11.702 but a majority of them were associated with Chukerman as rather than BD. 574 00:36:12.336 --> 00:36:15.339 So what are the implications of these findings? 575 00:36:16.040 --> 00:36:18.543 Based on previous literature, CDC recommends 576 00:36:18.543 --> 00:36:22.947 that all women diagnosed with BV can be tested for STIs. 577 00:36:23.581 --> 00:36:27.385 So perhaps for an individual with the positive BV not test, 578 00:36:27.418 --> 00:36:30.421 the same sample could also be reflex to other CI 579 00:36:30.721 --> 00:36:33.624 such as CT, Ng and TB. 580 00:36:35.126 --> 00:36:38.262 Future studies will be needed to assess the role of mycoplasma 581 00:36:38.429 --> 00:36:43.701 and thulium infections in individuals with natural vaginosis, and to understand 582 00:36:44.101 --> 00:36:47.205 what are the outcomes associated with those individuals 583 00:36:47.638 --> 00:36:50.641 with untreated infections. 584 00:36:52.510 --> 00:36:54.212 So to summarize, 585 00:36:54.212 --> 00:36:59.283 vaginosis is a common and leading reason women visit their ob gyn. 586 00:36:59.884 --> 00:37:02.887 It is has multiple etiologies 587 00:37:03.721 --> 00:37:06.023 with BV and check harmonizes 588 00:37:06.023 --> 00:37:11.229 and CV as the main three causes of most virgin itis, BV and Tacoma 589 00:37:11.229 --> 00:37:16.167 is associated with increased risk of HIV and transmission of other STIs. 590 00:37:17.101 --> 00:37:20.104 The diagnosis of vaginally is can be complicated 591 00:37:20.104 --> 00:37:23.641 and should be made using a combination of clinical findings, 592 00:37:24.575 --> 00:37:27.578 either office based or laboratory testing. 593 00:37:28.679 --> 00:37:32.350 Traditional diagnostic methods involve microscopy and culture, 594 00:37:32.783 --> 00:37:38.022 but more recent assays are shown to be sensitive and specific for vaginal itis 595 00:37:38.422 --> 00:37:42.593 and for Czech homeowners, but analysis alone, these are highly recommended. 596 00:37:43.261 --> 00:37:47.798 It's important to have specific diagnosis for vaginas for effective treatment. 597 00:37:49.033 --> 00:37:52.336 And finally, co-infection with other STIs is common, 598 00:37:52.737 --> 00:37:55.740 with implications for testing and patient management. 599 00:37:56.173 --> 00:37:58.909 With that, I'd like to thank you for your attention.