Clinical applications of custom-made vaginal cylinders constructed using three-dimensional printing technology.

PurposeThree-dimensional (3D) printing technology allows physicians to rapidly create customized devices for patients. We report our initial clinical experience using this technology to create custom applicators for vaginal brachytherapy.Material and methodsThree brachytherapy patients with unique clinical needs were identified as likely to benefit from a customized vaginal applicator. Patient 1 underwent intracavitary vaginal cuff brachytherapy after hysterectomy and chemotherapy for stage IA papillary serous endometrial cancer using a custom printed 2.75 cm diameter segmented vaginal cylinder with a central channel. Patient 2 underwent interstitial brachytherapy for a vaginal cuff recurrence of endometrial cancer after prior hysterectomy, whole pelvis radiotherapy, and brachytherapy boost. We printed a 2 cm diameter vaginal cylinder with one central and six peripheral catheter channels to fit a narrow vaginal canal. Patient 3 underwent interstitial brachytherapy boost for stage IIIA vulvar cancer with vaginal extension. For more secure applicator fit within a wide vaginal canal, we printed a 3.5 cm diameter solid cylinder with one central tandem channel and ten peripheral catheter channels. The applicators were printed in a biocompatible, sterilizable thermoplastic.ResultsPatient 1 received 31.5 Gy to the surface in three fractions over two weeks. Patient 2 received 36 Gy to the CTV in six fractions over two implants one week apart, with interstitial hyperthermia once per implant. Patient 3 received 18 Gy in three fractions over one implant after 45 Gy external beam radiotherapy. Brachytherapy was tolerated well with no grade 3 or higher toxicity and no local recurrences.ConclusionsWe established a workflow to rapidly manufacture and implement customized vaginal applicators that can be sterilized and are made of biocompatible material, resulting in high-quality brachytherapy for patients whose anatomy is not ideally suited for standard, commercially available applicators

Genome sequences of 14 Firmicutes strains isolated from the human vagina

Research on vaginal infections is currently limited by a lack of available fully sequenced bacterial reference strains. Here, we present strains (now available through BEI Resources) and genome sequences for a set of 14 vaginal isolates from the phylum Firmicutes. These genome sequences provide a valuable resource for future research in understanding the role of Gram-positive bacteria in vaginal health and disease

Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity.

OBJECTIVE: To assess the morbidity associated with continuing the second-stage duration of labor, weighing the probability of spontaneous vaginal birth without morbidity compared with birth with serious maternal or neonatal complications. METHODS: In a retrospective cohort, we analyzed singleton, vertex births at 36 weeks of gestation or greater without prior cesarean delivery (n=43,810 nulliparous and 59,605 multiparous women). We calculated rates of spontaneous vaginal birth and composite serious maternal or neonatal complications. Results were stratified by parity (nulliparous or multiparous) and epidural status (yes or no). Competing risks models were created for 1) spontaneous vaginal birth with no morbidity, 2) birth with maternal or neonatal morbidity, and 3) no spontaneous vaginal birth and no morbidity, and our main interest was in comparing number 1 against number 2. RESULTS: Rates of spontaneous vaginal birth without morbidity were slightly higher after the first half hour (greater than 0.5-1.0 hours) for nulliparous women, after which rates decreased with increasing second-stage duration. For multiparous women, rates of spontaneous vaginal birth without morbidity decreased with increasing second-stage duration. For illustration, for a nulliparous woman with an epidural at 3.0 hours of the second stage of labor who extended by another 1.0 hour, her likelihood of delivering by spontaneous vaginal birth was 31.4% compared with her likelihood of birth with any serious complication in the subsequent hour, which was 7.6%. The percentage of cesarean deliveries for nonreassuring fetal heart rate tracing were higher for women without compared with women with an epidural. CONCLUSION: Rates of spontaneous vaginal birth without serious morbidity steadily decreased for increasing second-stage duration except for the first half hour for nulliparous women. We did not observe an inflection point at a particular hour mark for either spontaneous vaginal delivery without morbidity or births with morbidity. Our findings will assist in decision-making for extending second-stage duration

Surface-enhanced Raman spectroscopy for the forensic analysis of vaginal fluid

Vaginal fluid is most often found at crime scenes where a sexual assault has taken place or on clothing or other items collected from sexual assault victims or perpetrators. Because the victim is generally known in these cases, detection of vaginal fluid is not a matter of individual identification, as it might be for semen identification. Instead, linkages can be made between victim and suspect if the sexual assault was carried out digitally or with a foreign object (e.g., bottle, pool cue, cigarette, handle of a hammer or other tool, etc.). If such an object is only analyzed for DNA and the victim is identified, the suspect may claim that the victim’s DNA is present because she handled and/or is the owner of the object and not because it was used to sexually assault her; identification of vaginal fluid residue would alleviate such uncertainty. Most of the research conducted thus far regarding methods for the identification of vaginal fluid involves mRNA biomarkers and identification of various bacterial strains.1-3 However, these approaches require extensive sample preparation and laboratory analysis and have not fully explored the genomic differences among all body fluid RNAs. No existing methods of vaginal fluid identification incorporate both high specificity and rapid analysis.4 Therefore, a new rapid detection method is required. Surface-enhanced Raman spectroscopy (SERS) is an emerging technique with high sensitivity for the forensic analysis of various body fluids. This technique has the potential to improve current vaginal fluid identification techniques due to its ease-of-use, rapid analysis time, portability, and non-destructive nature. For this experiment, all vaginal fluid samples were collected from anonymous donors by saturation of a cotton swab via vaginal insertion. Samples were analyzed on gold nanoparticle chips.4 This nanostructured metal substrate is essential for the large signal-enhancement effect of SERS and also quenches any background fluorescence that sometimes interferes with normal Raman spectroscopy measurements.5 Vaginal fluid SERS signal variation of a single sample over a six-month period was evaluated under both ambient and frozen storage conditions. Vaginal fluid samples were also taken from 10 individuals over the course of a single menstrual cycle. Four samples collected at one-week intervals were obtained from each individual and analyzed using SERS. The SERS vaginal fluid signals showed very little variation as a function of time and storage conditions, indicating that the spectral pattern of vaginal fluid is not likely to change over time. The samples analyzed over the span of one menstrual cycle showed slight intra-donor differences, however, the overall spectral patterns remained consistent and reproducible. When cycle spectra were compared between individuals, very little donor-to-donor variation was observed indicating the potential for a universal vaginal fluid signature spectrum. A cross-validated, partial least squares – discriminant analysis (PLS-DA) model was built to classify all body fluids, where vaginal fluid was identified with 95.0% sensitivity and 96.6% specificity, which indicates that the spectral pattern of vaginal fluid was successfully distinguished from semen and blood. Thus, SERS has a high potential for application in the field of forensic science for vaginal fluid analysis

Vaginal yeasts in the era of "over the counter" antifungals

OBJECTIVE: To establish whether there has been any rise in the prevalence of non-albicans Candida species isolated from vaginal swabs since the introduction of “over the counter” antifungal treatments. METHOD: A retrospective review looking at all positive vaginal yeast isolates collected from women attending one genitourinary medicine clinic during the 6 year period from 1993 to 1998 inclusive. All positive vaginal yeast isolates were included, regardless of whether or not the patients were symptomatic. Isolates from HIV positive women were excluded from the analysis. RESULT: No increase in non-albicans vaginal yeast isolates was shown during the period studied. The proportion of non-albicans yeasts remained constant at approximately 5% of the total yeasts isolated. The most common non-albicans yeast isolated was C glabrata. CONCLUSION: There is no evidence from this study to suggest that the increasing use of “over the counter” antifungal treatment has selected for atypical, possibly inherently azole resistant, strains of vaginal yeasts in HIV seronegative women

The Microbial Ecology of Bacterial Vaginosis: A Fine Scale Resolution Metagenomic Analysis

The vaginal microbiota play an important protective role in maintaining the health of women. Disruption of the mutualistic relationship that exists between bacterial communities in the vagina and their hosts can lead to bacterial vaginosis (BV), a condition in which lactic acid producing bacteria are supplanted by a diverse array of strictly anaerobic bacteria. BV has been shown to be an independent risk factor for adverse outcomes including preterm delivery and low infant birth weight, acquisition of sexually transmitted infections and HIV, and development of pelvic inflammatory disease. National surveys indicate the prevalence of BV among U.S. women is 29.2%, and yet, despite considerable effort, the etiology of BV remains unknown. Moreover, there are no broadly effective therapies for the treatment of BV, and reoccurrence is common. In the proposed research we will test the overarching hypothesis that vaginal microbial community dynamics and activities are indicators of risk to BV. To do this, we propose to conduct a high resolution prospective study in which samples collected daily from 200 reproductive-age women over two menstrual cycles are used to capture molecular events that take place before, during, and after the spontaneous remission of BV episodes. We will use modern genomic technologies to obtain the data needed to correlate shifts in vaginal microbial community composition and function, metabolomes, and epidemiological and behavioral metadata with the occurrence of BV to better define the syndrome itself and identify patterns that are predictive of BV. The three specific aims of the research are: (1) Evaluate the association between the dynamics of vaginal microbial communities and risk to BV by characterizing the community composition of vaginal specimens archived from a vaginal douching cessation study in which 33 women self-collected vaginal swabs twice-weekly for 16 weeks; (2) Enroll 135 women in a prospective study in which self-collected vaginal swab samples and secretions are collected daily along with data on the occurrence of BV, vaginal pH, and information on time varying habits and practices; (3) Apply model-based statistical clustering and classification approaches to associate the microbial community composition and function, with metadata and clinical diagnoses of BV. The large body of information generated will facilitate understanding vaginal microbial community dynamics, the etiology of BV, and drive the development of better diagnostic tools for BV. Furthermore, the information will enable a more personalized and effective treatment of BV and ultimately help prevent adverse sequelae associated with this highly prevalent disruption of the vaginal microbiome

Freeze-dried mucoadhesive polymeric system containing pegylated lipoplexes : towards a vaginal sustained released system for siRNA

peer reviewedTopical vaginal sustained delivery of siRNA presents a significant challenge due to the short residence time of formulations. Therefore, a drug delivery system capable to adhere to the vaginal mucosa is desirable, as it could allow a prolonged delivery and increase the effectiveness of the therapy. The aim of this project is to develop a polymeric solid mucoadhesive system, loaded with lipoplexes, able to be progressively rehydrated by the vaginal fluids to form a hydrogel and to deliver siRNA to vaginal tissues. To minimize adhesive interactions with vaginal mucus components, lipoplexes were coated with different derivatives of polyethylene glycol: DPSE-PEG2000, DPSE-PEG750 and ceramide-PEG2000. Based on stability and diffusion properties in simulated vaginal fluids, lipoplexes containing DSPE-PEG2000 were selected and incorporated in hydroxyethyl cellulose (HEC) hydrogels. Solid systems, called sponges, were then obtained by freeze-drying. Sponges meet acceptable mechanical characteristics and their hardness, eformability and mucoadhesive properties are not influenced by the presence of lipoplexes. Finally, mobility and stability of lipoplexes inside sponges rehydrated with vaginal mucus, mimicking in situ conditions, were evaluated by advanced fluorescence microscopy. The release rate was found to be influenced by the HEC concentration and consequently by the viscosity after rehydration. This study demonstrates the feasibility of entrapping pegylated lipoplexes into a solid matrix system for a prolonged delivery of siRNA into the vagina

Immunolocalization of steroidogenic enzymes in the vaginal mucous of Galea spixii during the estrous cycle.

BackgroundThe synthesis of sex steroids is controlled by several enzymes such as17α-hydroxylase cytochrome P450 (P450c17) catalyzing androgen synthesis and aromatase cytochrome P450 (P450arom) catalyzing estrogen synthesis, both of which must complex with the redox partner NADPH-cytochrome P450 oxidoreductase (CPR) for activity. Previous studies have identified expression of steroidogenic enzymes in vaginal tissue, suggesting local sex steroid synthesis. The current studies investigate P450c17, P450aromatase and CPR expression in vaginal mucosa of Galea spixii (Spix cavy) by immuno-histochemical and western immunoblot analyses.MethodsStages of estrous cyclicity were monitored by vaginal exfoliative cytology. After euthanasia, vaginal tissues were retrieved, fixed and frozen at diestrus, proestrus, estrus and metestrus. The ovaries and testis were used as positive control tissues for immunohistochemistry.ResultsData from cytological study allowed identification of different estrous cycle phases. Immunohistochemical analysis showed different sites of expression of steroidogenic enzymes along with tissue response throughout different phases of the estrous cycle. However, further studies are needed to characterize the derived hormones synthesized by, and the enzymes activities associated with, vaginal tissues.ConclusionCurrent results not only support the expression of enzymes involved in sex steroid synthesis in the wall of the vagina, they also indicate that expression changes with the stage of the cycle, both the levels and types of cells exhibiting expression. Thus, changes in proliferation of vaginal epithelial cells and the differentiation of the mucosa may be influenced by local steroid synthesis as well as circulating androgens and estrogens

Genome sequences of 11 human vaginal Actinobacteria strains

The composition of the vaginal microbiota is an important health determinant. Several members of the phylum Actinobacteria have been implicated in bacterial vaginosis, a condition associated with many negative health outcomes. Here, we present 11 strains of vaginal Actinobacteria (now available through BEI Resources) along with draft genome sequences

The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy

OBJECTIVE: To compare the effects of laparoscopic hysterectomy and abdominal hysterectomy in the abdominal trial, and laparoscopic hysterectomy and vaginal hysterectomy in the vaginal trial. DESIGN: Two parallel, multicentre, randomised trials. Setting 28 UK centres and two South African centres. Participants 1380 women were recruited; 1346 had surgery; 937 were followed up at one year. PRIMARY OUTCOME: outcome Rate of major complications. RESULTS: In the abdominal trial laparoscopic hysterectomy was associated with a higher rate of major complications than abdominal hysterectomy (11.1% v 6.2%, P = 0.02; difference 4.9%, 95% confidence interval 0.9% to 9.1%) and the number needed to treat to harm was 20. Laparoscopic hysterectomy also took longer to perform (84 minutes v 50 minutes) but was less painful (visual analogue scale 3.51 v 3.88, P = 0.01) and resulted in a shorter stay in hospital after the operation (3 days v 4 days). Six weeks after the operation, laparoscopic hysterectomy was associated with less pain and better quality of life than abdominal hysterectomy (SF-12, body image scale, and sexual activity questionnaires). In the vaginal trial we found no evidence of a difference in major complication rates between laparoscopic hysterectomy and vaginal hysterectomy (9.8% v 9.5%, P = 0.92; difference 0.3%, − 5.2% to 5.8%), and the number needed to treat to harm was 333.We found no evidence of other differences between laparoscopic hysterectomy and vaginal hysterectomy except that laparoscopic hysterectomy took longer to perform (72 minutes v 39 minutes) and was associated with a higher rate of detecting unexpected pathology (16.4% v 4.8%, P = < 0.01). However, this trial was underpowered. CONCLUSIONS: Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time