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1.  Deprivation and poor psychosocial support are key determinants of late antenatal presentation and poor fetal outcomes-a combined retrospective and prospective study 
Background
Published guidelines emphasise the need for early antenatal care to promote maternal and neonatal health. Inadequate engagement with antenatal care is associated with adverse pregnancy outcomes including maternal death. The factors that influence the uptake and utilisation of maternity care services are poorly understood. We retrospectively explore a large maternity database of births in a large referral UK hospital to capture the socio-demographic factors that influence late pregnancy booking, and then prospectively compare the stress and social support status of consenting early and late-booking women.
Methods
Retrospective socio-demographic and clinical outcome data on 59,487 women were collected from the maternity database record of births between 2002 and 2010 at the Jessop Wing Hospital, Sheffield UK. In a follow-on prospective survey between October 2012 and May 2013 a convenience cohort of early and late bookers for antenatal care were then studied using validated scales for fetomaternal attachment, stress and anxiety, and social support.
Results
In our retrospective study, pregnancy during the teenage years, higher parity, non-white ethnic background, unemployment and smoking were significantly associated with late access to antenatal services and poor fetal outcomes (P < 0.001). However, late booking per se did not predict adverse fetal outcomes, when socio-demographic factors were accounted for. A high index of multiple deprivation (IMD) score remained independently associated with late booking when confounding factors such as ethnicity and employment status were controlled for in the model (P = 0.03). Our prospective data demonstrated that women who book late were more likely to be unmarried (OR: 3.571, 95 % CI: 1.464–8.196, p = 0.005), of high parity (OR: 1.759, 95 % CI: 1.154–2.684, P = 0.009), and have lower social support than early bookers (P = 0.047).
Conclusions
Of the many complex sociocultural factors that influence the timing of maternal engagement with antenatal care, multiple deprivation and poor social support remain key factors. Improving access to prenatal care requires in-depth exploration of the relationship between maternal psychosocial health indices, social support mechanisms and engagement with antenatal care. Findings from these studies should inform interventions aimed at improving access to care.
Electronic supplementary material
The online version of this article (doi:10.1186/s12884-015-0753-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12884-015-0753-3
PMCID: PMC4660789  PMID: 26608259
Pregnancy; Antenatal care; Access; Late booking; Social exclusion; Deprivation
2.  Long-term Effect of Depot Medroxyprogesterone Acetate on Vaginal Microbiota, Epithelial Thickness and HIV Target Cells 
The Journal of Infectious Diseases  2014;210(4):651-655.
Background. Depot medroxyprogesterone acetate (DMPA) has been linked to human immunodeficiency virus type 1 (HIV-1) acquisition.
Methods. Vaginal microbiota of women using DMPA for up to 2 years were cultured. Mucosal immune cell populations were measured by immunohistological staining.
Results. Over 12 months, the proportion with H2O2-positive lactobacilli decreased (n = 32; 53% vs 27%; P = .03). Median vaginal CD3+ cells also decreased (n = 15; 355 vs 237 cells/mm2; P = .03), as did CD3+CCR5+ cells (195 vs 128 cells/mm2; P = .04), HLA-DR+ cells (130 vs 96 cells/mm2; P = .27), and HLA-DR+CCR5+ cells (18 vs 10 cells/mm2; P = .33).
Conclusions. DMPA contraception does not increase vaginal mucosal CCR5+ HIV target cells but does decrease CD3+ T lymphocytes and vaginal H2O2-producing lactobacilli.
doi:10.1093/infdis/jiu176
PMCID: PMC4172039  PMID: 24652495
HIV; medroxyprogesterone acetate; vaginal mucosa
3.  Sexual Function in Women on Estradiol or Venlafaxine for Hot Flushes: A Randomized Controlled Trial 
Obstetrics and gynecology  2014;124(2 0 1):233-241.
Objective
To evaluate sexual function in midlife women taking low-dose oral estradiol or venlafaxine for hot flushes.
Methods
In an 8-week randomized controlled trial among women aged 40-62 years, sexual function was compared between oral estradiol 0.5 mg/day or venlafaxine 75 mg/day (both compared with placebo). Measures included composite and 6 domain scores from the Female Sexual Function Index (FSFI) and sexually related personal distress.
Results
Participants were aged 54.6 (standard deviation [SD] 3.8) years, 59% Caucasian, with 8.1 (SD 5.3) daily hot flushes. Median composite baseline FSFI score was 16.3 (SD 11.9, n=256) for all women and 21.7 (SD 9.3, n=198) among sexually active women. Composite mean FSFI change from baseline to week-8 was 1.4 (95% Confidence Interval [CI] -0.4, 3.2) for estradiol, 1.1 (95% CI -0.5, 2.7) for venlafaxine and -0.3 (95% CI -1.6, 1.0) for placebo. Composite FSFI and sexually-related distress change from baseline did not differ between estradiol and placebo (p= 0.38, p=0.30) or venlafaxine and placebo (p=0.79, p=0.48). Among sexually active women, FSFI domain score change from baseline differences (active compared with placebo) in desire was 0.3 (95% CI 0.0, 0.6) for estradiol; -0.6 (95% CI -1.2, 0.0) in orgasm for venlafaxine, and 0.9 (95% CI 0.2, 1.6) in penetration pain for venlafaxine. No women reported adverse events related to sexual dysfunction.
Conclusions
Overall sexual function among nondepressed midlife women experiencing hot flushes did not change over 8-weeks with low-dose oral estradiol or venlafaxine (compared with placebo), although subtle increase in desire (estradiol), and decreases in orgasm and pain (venlafaxine) may exist.
doi:10.1097/AOG.0000000000000386
PMCID: PMC4113909  PMID: 25004335
4.  Bacterial vaginosis and the cervicovaginal immune response 
Bacterial vaginosis (BV) is a common cause of vaginal discharge in reproductive age women around the world, and is associated with several poor reproductive health outcomes, including HIV-1 acquisition. One possible mechanism for this association is the inflammatory immune response induced by BV in the cervical and vaginal mucosae. There is significant heterogeneity in reports of markers of cervicovaginal inflammation in women with bacterial vaginosis, likely due to microbial and host diversity, as well as differences in study design. In this article we review the characteristics of the mucosal immune response in BV, the potential role of lactobacilli in modulating that response, and the impact of individual BV-associated bacterial species on mucosal immunity. We focus on inflammatory markers that are proposed to increase the risk of HIV-1 acquisition.
doi:10.1111/aji.12264
PMCID: PMC4128638  PMID: 24832618
5.  The Vagina Dialogues 
Menopause (New York, N.Y.)  2014;21(5):437-438.
doi:10.1097/GME.0000000000000224
PMCID: PMC4001831  PMID: 24594865
6.  Low Concentrations of HIV-1 DNA at Birth Delays Diagnosis, Complicating Identification of Infants for Antiretroviral Therapy to Potentially Prevent the Establishment of Viral Reservoirs 
Among infants exposed to human immunodeficiency virus type 1 (HIV-1), detection of viral infection at birth was increased by 39% (95% confidence interval, 19%–47%) by increasing DNA input from dried blood spots into polymerase chain reaction. Infants with low concentrations of HIV-1 at birth may be the best target population to evaluate whether immediate antiretroviral therapy can prevent long-term infection.
doi:10.1093/cid/ciu068
PMCID: PMC3967830  PMID: 24501389
HIV-1; infant diagnosis; HIV-1 DNA; mother-to-child transmission; HIV-1 cure
8.  Simple sequence repeat markers for the endangered species Clianthus puniceus and C. maximus (Fabaceae)1 
Applications in Plant Sciences  2015;3(1):apps.1400102.
• Premise of the study: Microsatellite markers were developed for Clianthus puniceus using a shotgun sequencing library and tested for cross amplification in the closely related C. maximus to inform population management of these two endangered species.
• Methods and Results: We constructed a shotgun sequencing library using a Roche 454 sequencer and searched the resulting data set for putative microsatellite regions. We optimized 12 of these regions to produce polymorphic markers for Clianthus. We tested these markers on four populations of C. maximus and on four C. puniceus individuals of known provenance. Alleles per locus ranged from two to nine, while observed and expected heterozygosities per locus ranged from 0.000 to 1.000 and 0.178 to 0.600, respectively.
• Conclusions: These markers will be valuable for ongoing monitoring of the genetic variation in naturally occurring populations of Clianthus and for the selection of individuals for revegetation projects in the species’ former range.
doi:10.3732/apps.1400102
PMCID: PMC4298236  PMID: 25606358
Clianthus maximus; Clianthus puniceus; Fabaceae; simple sequence repeats (SSRs)
9.  Pelvic Inflammatory Disease: Current concepts in pathogenesis, diagnosis and treatment 
Infectious disease clinics of North America  2013;27(4):10.1016/j.idc.2013.08.004.
doi:10.1016/j.idc.2013.08.004
PMCID: PMC3843151  PMID: 24275271
10.  Correlation between Plasma, Intracellular, and Cervical Tissue Levels of Raltegravir at Steady-State Dosing in Healthy Women 
Raltegravir is an antiretroviral with potential value for preexposure prophylaxis (PrEP) against HIV, but the intracellular pharmacokinetics in genital tissue have not been described. In this study, healthy, HIV-uninfected nonpregnant women took 400 mg of raltegravir twice daily for 22 days. On day 8, 15, and 22, blood was collected 0, 4, 6, 8, and 12 h and cervical biopsy specimens taken 0, 6, and 12 h after raltegravir dosing. Plasma and intracellular raltegravir concentrations in peripheral blood mononuclear cells (PBMC) and cervical tissue were measured by tandem mass spectrometry. Linear mixed effects models evaluated correlations between different sample types, as well as differences in concentration between phases of the menstrual cycle. Ten women were enrolled: 9 completed all three visits and 1 completed two visits. The age (mean ± standard deviation) of participants was 30 ± 8 years. Trough plasma concentrations of raltegravir 12 h after a directly observed dose were above the HIV 95% inhibitory concentration (IC95) of 33 nM (14.6 ng/ml) in 96% of measurements, compared to 67% of PBMC and 89% of cervical tissue trough values. Across all measurements, only 2% (3/135) of plasma values fell below the IC95, compared to 10% (13/135) for PBMC and 6% (5/81) for cervical tissue. There was no impact of menstrual phase on raltegravir concentrations. In conclusion, cervical tissue raltegravir concentrations were no greater than plasma concentrations, and ∼10% of all cervical tissue trough values were below the IC95, making the current twice-daily formulation of raltegravir impractical for PrEP.
doi:10.1128/AAC.02757-13
PMCID: PMC4068472  PMID: 24687503
11.  Predicting biopsychosocial outcomes for heroin users in primary care treatment: a prospective longitudinal cohort study 
The British Journal of General Practice  2013;63(612):e499-e505.
Background
Opiate substitution treatment for heroin users reduces mortality, illicit drug use, crime, and risk-taking behaviour, and improves physical, mental and social functioning. Few extended studies have been carried out in UK primary care to study factors predicting recovery.
Aim
To establish whether primary care opiate substitution treatment is associated with improvements in outcomes over 11 years, in delivering recovery, and to identify predictive factors.
Design and setting
A prospective longitudinal cohort study, with repeated measures in the Primary Care Addiction Service, Sheffield, 1999–2011.
Method
A total of 123 eligible patients were assessed using the Opiate Treatment Index at entry to treatment and at 1, 5, and 11 years. Clinical records were used to assess factors including employment and discharge status.
Results
At 11 years, there was a high rate of drug-free discharge (22.0%) and medically-assisted recovery (30.9%), and low mortality (6.5%). Continuous treatment was associated with being discharged drug free (P = 0.005). For those still in treatment, there were highly significant reductions in heroin use and injecting, and significantly improved psychosocial functioning. There were strong positive correlations between mental health, physical health, and social functioning. Patients in employment had significantly better psychological and social functioning (P = 0.017, P = 0.007, respectively).
Conclusion
Opiate substitution treatment is associated over 11 years with full recovery, drug-free discharge and medically-assisted recovery. There is a strong association between the psychosocial variables, suggesting that intervention in any one of these areas may have extended benefits, by impacting on related variables and employment. The best predictor of a drug-free discharge was continuous uninterrupted treatment.
doi:10.3399/bjgp13X669220
PMCID: PMC3693807  PMID: 23834887
biopsychosocial outcomes; heroin users; opiate substitution therapy; predictive factors; primary care; recovery capital
12.  Understanding delayed access to antenatal care: a qualitative interview study 
Background
Delayed access to antenatal care ('late booking’) has been linked to increased maternal and fetal mortality and morbidity. The aim of this qualitative study was to understand why some women are late to access antenatal care.
Methods
27 women presenting after 19 completed weeks gestation for their first hospital booking appointment were interviewed, using a semi-structured format, in community and maternity hospital settings in South Yorkshire, United Kingdom. Interviews were transcribed verbatim and entered onto NVivo 8 software. An interdisciplinary, iterative, thematic analysis was undertaken.
Results
The late booking women were diverse in terms of: age (15–37 years); parity (0–4); socioeconomic status; educational attainment and ethnicity. Three key themes relating to late booking were identified from our data: 1) 'not knowing’: realisation (absence of classic symptoms, misinterpretation); belief (age, subfertility, using contraception, lay hindrance); 2) 'knowing’: avoidance (ambivalence, fear, self-care); postponement (fear, location, not valuing care, self-care); and 3) 'delayed’ (professional and system failures, knowledge/empowerment issues).
Conclusions
Whilst vulnerable groups are strongly represented in this study, women do not always fit a socio-cultural stereotype of a 'late booker’. We report a new taxonomy of more complex reasons for late antenatal booking than the prevalent concepts of denial, concealment and disadvantage. Explanatory sub-themes are also discussed, which relate to psychological, empowerment and socio-cultural factors. These include poor reproductive health knowledge and delayed recognition of pregnancy, the influence of a pregnancy 'mindset’ and previous pregnancy experience, and the perceived value of antenatal care. The study also highlights deficiencies in early pregnancy diagnosis and service organisation. These issues should be considered by practitioners and service commissioners in order to promote timely antenatal care for all women.
doi:10.1186/1471-2393-14-207
PMCID: PMC4072485  PMID: 24935100
Pregnancy; Antenatal care; Access; Late booking; Qualitative study
13.  Sophora microphylla (Fabaceae) microsatellite markers and their utility across the genus1 
Applications in Plant Sciences  2014;2(3):apps.1300081.
• Premise of the study: Genus-specific microsatellite markers were developed for Sophora for population genetic and systematic studies of the group in New Zealand, and potentially elsewhere in the geographic range.
• Methods and Results: From sequencing a total genomic DNA library (using Roche 454), we identified and developed 29 polymorphic microsatellite markers for S. microphylla and S. chathamica. We tested 12 of these markers on 14 S. chathamica individuals and four S. microphylla populations. All loci amplified in both species and species-specific alleles occurred at seven loci. In S. microphylla populations, the observed and expected heterozygosities ranged from 0.000–0.960 and 0.000–0.908, respectively, with alleles per locus ranging from seven to 23.
• Conclusions: The developed markers will be valuable in studies of phylogenetics, population structure, mating system, and selection of provenances for restoration projects.
doi:10.3732/apps.1300081
PMCID: PMC4103103  PMID: 25202609
Fabaceae; genetic variation; simple sequence repeat markers; Sophora microphylla
14.  Associations between genital tract infections, genital tract inflammation and cervical cytobrush HIV-1 DNA in US versus Kenyan women 
Cervical shedding of HIV-1 DNA may influence HIV-1 sexual transmission. HIV-1 DNA was detected in 250/316 (80%) and 207/259 (79%) cervical cytobrush specimens from 56 United States (US) and 80 Kenyan women, respectively. Plasma HIV-1 RNA concentration was associated with increased HIV-1 DNA shedding among US and Kenyan women. Kenyan women had higher cervicovaginal concentrations of pro-inflammatory interleukins (IL)-1β, IL-6, IL-8 and anti-inflammatory secretory leukocyte protease inhibitor (SLPI) compared to US women (all p < 0.01). HIV-1 DNA shedding was associated with increased concentrations of IL-1β and IL-6 and lower SLPI among US women, but not Kenyan women.
doi:10.1097/QAI.0b013e318274577d
PMCID: PMC3549039  PMID: 23018377
15.  Associations between vaginal bacteria and levels of vaginal defensins in pregnant women 
Objective
We evaluated vaginal defensin concentrations and levels of BV-associated bacterial species in pregnant women.
Study Design
Self-collected vaginal swabs from two visits during pregnancy were tested with qPCR for nine bacterial species. Beta defensin 2 (HBD2), HBD3 and alpha defensins 1–3 (HNP1–3) were measured by ELISA.
Results
Our 126 participants were primarily African American (60%), had a mean gestational age at enrollment of 10 weeks (±3) and at follow-up of 25 weeks (± 6). At enrollment, prevalence of BV was 74% (94/126), which decreased to 60% (75/126) at follow-up. At enrollment, HBD3 concentrations were significantly lower in women with BV (2.64 + 0.91 vs. 3.25 + 0.99 log10 pg/mL; p = 0.003). Higher concentrations of Atopobium vaginae, BVAB1 and BVAB2 were associated with significantly lower concentrations of HBD3 (p < 0.01).
Conclusions
BV was associated with lower vaginal concentrations of HBD3, but not HBD2 or HNP1–3, in pregnant women.
doi:10.1016/j.ajog.2012.11.019
PMCID: PMC3623553  PMID: 23174285
Bacterial vaginosis; Defensins; Innate immunity in pregnancy
16.  Interaction Between Lactobacilli, Bacterial Vaginosis-Associated Bacteria, and HIV Type 1 RNA and DNA Genital Shedding in U.S. and Kenyan Women 
Abstract
Bacterial vaginosis has been associated with genital HIV-1 shedding; however, the effect of specific vaginal bacterial species has not been assessed. We tested cervicovaginal lavage from HIV-1-seropositive women for common Lactobacillus species: L. crispatus, L. jensenii, and seven BV-associated species: BVAB1, BVAB2, BVAB3, Leptotrichia, Sneathia, Megasphaera, and Atopobium spp. using quantitative PCR. We used linear and Poisson regression to evaluate associations between vaginal bacteria and genital HIV-1 RNA and DNA. Specimens from 54 U.S. (310 visits) and 50 Kenyan women (137 visits) were evaluated. Controlling for plasma viral load, U.S. and Kenyan women had similar rates of HIV-1 RNA (19% of visits vs. 24%; IRR=0.95; 95% CI 0.61, 1.49) and DNA shedding (79% vs. 76%; IRR=0.90; 0.78, 1.05). At visits during antiretroviral therapy (ART), the likelihood of detection of HIV-1 RNA shedding was greater with BVAB3 (IRR=3.16; 95% CI 1.36, 7.32), Leptotrichia, or Sneathia (IRR=2.13; 1.02, 4.72), and less with L. jensenii (IRR=0.39; 0.18, 0.84). At visits without ART, only L. crispatus was associated with a lower likelihood of HIV-1 RNA detection (IRR=0.6; 0.40, 0.91). Vaginal Lactobacillus species were associated with lower risk of genital HIV-1 shedding, while the presence of certain BV-associated species may increase that risk.
doi:10.1089/aid.2012.0187
PMCID: PMC3537306  PMID: 23020644
17.  Effect of Sexual Debut on Vaginal Microbiota in a Cohort of Young Women 
Obstetrics and gynecology  2012;120(6):1306-1313.
Background
Bacterial vaginosis is uncommon in women who are virgins. We estimated effects of sexual debut on vaginal bacterial colonization.
Methods
Women who were virgins and aged 18–22 enrolled in a study of human papillomavirus acquisition were followed every 4 months for up to 2 years. Vaginal swabs from before and after sexual debut, or two independent visits for those remaining virginal were tested by quantitative polymerase chain reaction for Lactobacillus crispatus, L. jensenii, L. iners, Gardnerella vaginalis, and the bacterial vaginosis-associated species Atopobium vaginae, Megasphaera spp., Leptotrichia spp, Sneathia, spp BVAB1, BVAB2, and BVAB3.
Results
We evaluated 97 women: 71 who became sexually active and 26 who remained virginal. At first sampling, 22/26 (85%) of women who remained virginal were colonized with Lactobacillus species compared to 22/26 (85%) at follow-up (p > 0.99). G. vaginalis was present in 12/26 (46%) initially, and 11/26 (42%) at follow-up (p > 0.99). Among women who became sexually active, colonization with Lactobacillus species remained stable: 65/71 (92%) vs. 66/71 (93%) (p > 0.99), while colonization with G. vaginalis increased [28/71 (39%) vs 40/71 (56%); p = 0.02]. Among women who did not initiate sexual activity during the study, 2/26 (8%) had any bacterial vaginosis-associated species detected at both the first and second visits(p > 0.99). Among women who became sexually active during the study 15/71 (21%) were colonized with bacterial vaginosis-associated species initially, compared to 13/71 (18%) after sexual debut (p = 0.77).
Conclusions
Among women who were virgins, vaginal colonization with bacterial vaginosis-associated bacterial species is uncommon and does not change after sexual debut.
PMCID: PMC3548407  PMID: 23168754
18.  Survey of patients' view on functional split of consultant psychiatrists 
Background
The functional split model of consultant psychiatrist care for inpatients has been one of the major service redesign that has occurred in the NHS in the last decade. It is unclear if this new split model offers any advantages over the previous sectorised model of working. More recent evidence has suggested that patients, carers and professionals have varied views regarding the benefits of this model.
This survey of patient’s views on models of consultant working is the first in Scotland and we have attempted to include a large sample size. The results suggest that after providing sufficient information on both models, the majority of patients from various Scottish health boards have opted for the traditional sectorised model of working.
Method
During a four week period consecutive patients across 4 health boards attending the General Adult consultant outpatient clinics and those who were admitted to their inpatient ward were offered a structured questionnaire regarding their views on the functional split versus traditional sectorised model. Space was provided for additional comments. The study used descriptive statistical measures for analysis of its results. Ethical approval was confirmed as not being required for this survey of local services.
Results
We had a response rate of 67%. A significant majority (76%) of service users across the four different health boards indicated a preference for the same consultant to manage their care irrespective of whether they were an inpatient or in the community (Chi-squared = 65, df = 1, p < 0.0001). In their unstructured comments patients often mentioned the value of the therapeutic relationship and trust in a single consultant psychiatrist.
Conclusions
Our survey suggests that most patients prefer the traditional model where they see a single consultant throughout their journey of care. The views of patients should be sought as much as possible and should be taken into account when considering the best way to organize psychiatric services.
doi:10.1186/1472-6963-13-362
PMCID: PMC3849881  PMID: 24074270
Functional split; Inpatient psychiatric care; New ways of working
19.  Healthy Neonates Possess a CD56-Negative NK Cell Population with Reduced Anti-Viral Activity 
PLoS ONE  2013;8(6):e67700.
Background
Neonatal Natural Killer (NK) cells show functional impairment and expansion of a CD56 negative population of uncertain significance.
Methods
NK cells were isolated from cord blood and from adult donors. NK subpopulations were identified as positive or negative for the expression of CD56 and characterized for expression of granzyme B and surface markers by multi-parameter flow cytometry. Cell function was assessed by viral suppression and cytokine production using autologous lymphocytes infected with HIV. Activating (NKp30, NKp46) and inhibitory (Siglec-7) markers in healthy infants and adults were compared with viremic HIV-infected adults.
Results
Cord blood contained increased frequencies of CD56 negative (CD56neg) NK cells with reduced expression of granzyme B and reduced production of IFNγ and the CC-class chemokines RANTES, MIP1α and MIP1β upon stimulation. Both CD56pos and CD56neg NK subpopulations showed impaired viral suppression in cord blood, with impairment most marked in the CD56neg subset. CD56neg NK cells from cord blood and HIV-infected adults shared decreased inhibitory and activating receptor expression when compared with CD56pos cells.
Conclusions
CD56neg NK cells are increased in number in normal infants and these effectors show reduced anti-viral activity. Like the expanded CD56neg population described in HIV-infected adults, these NK cells demonstrate functional impairments which may reflect inadequate development or activation.
doi:10.1371/journal.pone.0067700
PMCID: PMC3689709  PMID: 23805324
20.  Transmitted HIV Resistance to First-Line Antiretroviral Therapy in Lima, Peru 
Abstract
Transmission of drug-resistant HIV (TDR) has been associated with virologic failure of “first-line,” nonnucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART). A national ART program began in Peru in 2004. We evaluated the prevalence of TDR in individuals initiating ART and their virologic outcome during 2 years of ART. HIV-infected, ARV-naive subjects who met criteria to start ART in Lima, Peru were enrolled in a longitudinal observational study between July 2007 and February 2009. Blood plasma and cells obtained prior to ART initiation were assessed for antiretroviral (ARV) resistance by an oligonucleotide ligation assay (OLA) sensitive to 2% mutant at reverse transcriptase (RT) codons K103N, Y181C, G190A, and M184V and a subset by consensus sequencing. A total of 112 participants were enrolled; the mean CD4 was 134±89 cells/μl and the median plasma HIV RNA was 93,556 copies/ml (IQR 62,776–291,364). Drug resistance mutations conferring high-level resistance to ARV were rare, detected in one of 96 (1%) evaluable participants. This subject had the Y181C mutation detected in both plasma and peripheral blood mononuclear cells (PBMCs) at a concentration of 100% by OLA and consensus sequencing; nevertheless nevirapine-ART suppressed her viral replication. Consensus sequencing of 37 (19%) participants revealed multiple polymorphisms that occasionally have been associated with low-level reductions in ARV susceptibility. A low prevalence of TDR was detected among Peruvians initiating ART. Given the increasing availability of ART, continuing surveillance is needed to determine if TDR increases and the mutant codons associated with virologic failure.
doi:10.1089/aid.2011.0131
PMCID: PMC3316114  PMID: 21819256
21.  Effect of sexual activity on vaginal colonization with hydrogen-peroxide producing Lactobacilli and Gardnerella vaginalis 
Sexually transmitted diseases  2011;38(12):1137-1144.
Background
Bacterial vaginosis is associated with sexual activity, but mechanisms for this association are unclear.
Study Design
Cross-sectional analysis of data from women reporting sex with women who provided information on sexual behaviors as part of a study of vaginal bacteria. Vaginal bacteria were detected by semi-quantitative culture. Binomial regression with log-link evaluated associations between detection of bacteria and sexual behaviors reported to occur prior to enrollment. Linear regression evaluated associations between these behaviors and quantity of bacteria.
Results
Of 320 women, 216 (68%) were colonized with H2O2-producing lactobacilli and 142 (44%) with G. vaginalis. Colonization with G. vaginalis was associated with >20 digital-vaginal sex acts (RR 2.01; 1.22, 3.29) or >10 toy-vaginal acts in the past 3 months (RR 1.76; 1.32, 2.36). Quantity of H2O2-producing lactobacilli was 1.3 log lower in colonized women reporting >10 acts of insertive vaginal sex toy use in the past 3 months (95%CI −2.04, −.56), 1.19 log lower with toy-vaginal sex in past 7 days (−1.75, −.62), and 0.78 log lower in women sharing toys with a partner (−1.25, −.31).
Conclusions
Vaginal insertive use and sharing of sex toys was associated with decreased quantities of H2O2-producing lactobacilli and higher risk of colonization with G. vaginalis.
doi:10.1097/OLQ.0b013e31822e6121
PMCID: PMC3217189  PMID: 22082725
bacterial vaginosis; lactobacilli; Gardnerella vaginalis
22.  Detection of hydrogen peroxide-producing Lactobacillus species in the vagina: a comparison of culture and quantitative PCR among HIV-1 seropositive women 
BMC Infectious Diseases  2012;12:188.
Background
The presence of hydrogen peroxide (H2O2) producing Lactobacillus in the vagina may play a role in controlling genital HIV-1 shedding. Sensitive molecular methods improve our ability to characterize the vaginal microbiota; however, they cannot characterize phenotype. We assessed the concordance of H2O2-producing Lactobacillus detected by culture with quantitative PCR (qPCR) detection of Lactobacillus species commonly assumed to be H2O2-producers.
Methods
Samples were collected as part of a prospective cohort study of HIV-1 seropositive US women. Cervicovaginal lavage specimens were tested for L. crispatus and L. jensenii using 16S rRNA gene qPCR assays. Vaginal swabs were cultured for Lactobacillus and tested for H2O2-production. We calculated a kappa statistic to assess concordance between culture and qPCR.
Results
Culture and qPCR results were available for 376 visits from 57 women. Lactobacilli were detected by culture at 308 (82%) visits, of which 233 of 308 (76%) produced H2O2. L. crispatus and/or L. jensenii were detected at 215 (57%) visits. Concordance between detection of L. crispatus and/or L. jensenii by qPCR and H2O2-producing Lactobacillus by culture was 75% (kappa = 0.45).
Conclusions
Among HIV-1 seropositive women, there was a moderate level of concordance between H2O2-producing Lactobacillus detected by culture and the presence of L. crispatus and/or L. jensenii by qPCR. However, one-quarter of samples with growth of H2O2-producing lactobacilli did not have L. crispatus or L. jensenii detected by qPCR. This discordance may be due to the presence of other H2O2-producing Lactobacillus species.
doi:10.1186/1471-2334-12-188
PMCID: PMC3462152  PMID: 22889380
Lactobacillus; Lactobacillus crispatus; Lactobacillus jensenii; Bacterial vaginosis; Culture; Hydrogen peroxide; 16S rRNA gene
23.  Behavioral Predictors of Colonization with Lactobacillus crispatus or Lactobacillus jensenii after Treatment for Bacterial Vaginosis: A Cohort Study 
Objective: Evaluate predictors of vaginal colonization with lactobacilli after treatment for bacterial vaginosis (BV). Methods. Vaginal fluid specimens from women with BV underwent qPCR for Lactobacillus crispatus, L. jensenii, and L. iners pre- and posttreatment. Results. Few women with BV were colonized with L. crispatus (4/44, 9%) or L. jensenii (1/44, 2%), though all had L. iners. One month posttreatment 12/44 (27%) had L. crispatus, 12/44 (27%) L. jensenii, and 43/44 (98%) L. iners. Presence of L. jensenii posttreatment was associated with cure (Risk Ratio (RR) 1.67; 95% CI 1.09–2.56); L. crispatus showed a similar trend (RR 1.41; 95% CI 0.89–2.24, P = 0.14). Receptive oral sex was associated with 2.2-log10 lower concentration of L. crispatus (95% CI −4.38, −.02), and digital-vaginal sex with 2.6-log10 lower concentration (95% CI −4.87, −.33). Conclusion. One month after BV treatment, few women established colonization with L. crispatus or L. jensenii. Few behaviors were associated with colonization.
doi:10.1155/2012/706540
PMCID: PMC3369434  PMID: 22693410
24.  Impact of the QOF and the NICE guideline in the diagnosis andmanagement of depression: a qualitative study 
The British Journal of General Practice  2011;61(586):e279-e289.
Background
The National Institute for Health and clinical Excellence (NICE) depression guideline (2004) and the updated Quality and Outcomes Framework (QOF) ( 2006) in general practice have introduced the concepts of screening severity assessment, for example using the Patient Health Questionnaire 9 (PHQ-9), and ‘stepped care’ for depression.
Aim
To explore primary care practitioner perspectives on the clinical utility of the NICE guideline and the impact of the QOF on diagnosis and management of depression in routine practice.
Design and setting
Qualitative study using focus groups from four multidisciplinary practice teams with diverse populations in south Yorkshire.
Method
Four focus groups were conducted, using a topic guide and audiotaping. There were 38 participants: GPs, nurses, doctors in training, mental health workers, and a manager. Data analysis was iterative and thematic.
Results
The NICE guideline, with its embedded principles of holism and evidence-based practice, was viewed positively but its impact was compromised by resource and practitioner barriers to implementation. The perceived imposition of the screening questions and severity assessments (PHQ-9) with no responsive training had required practitioners to work hard to minimise negative impacts on their work, for example: constantly adapting consultations to tick boxes; avoiding triggering open displays of distress without the time to offer appropriate care; positively managing how their patients were labelled. Further confusion was experienced around the evolving content of psychological interventions for depression.
Conclusion
Organisational barriers to the implementation of the NICE guideline and the limited scope of the QOF highlight the need for policy makers to work more effectively with the complex realities of general practice in order to systematically improve the quality and delivery of ‘managed’ care for depression.
doi:10.3399/bjgp11X572472
PMCID: PMC3080233  PMID: 21619752
depression; primary health care; qualitative
25.  Cervicovaginal Shedding of HIV Type 1 Is Related to Genital Tract Inflammation Independent of Changes in Vaginal Microbiota 
Abstract
We examined the relationship of proinflammatory vaginal cytokines and secretory leukocyte protease inhibitor (SLPI) with genital HIV-1 shedding after controlling for genital coinfections. Fifty-seven HIV-1-infected women in Seattle, WA (n = 38) and Rochester, NY (n = 19) were followed every 3–4 months for a total of 391 visits. At each visit, plasma and cervicovaginal lavage (CVL) were tested for HIV-1 RNA using qPCR. Vaginal samples were tested for bacterial vaginosis, yeast, hydrogen peroxide-producing Lactobacillus colonization, Trichomonas vaginalis, Neisseria gonorrhea, Chlamydia trachomatis, CMV, and HSV shedding. CVL interleukins (IL)-1β, IL-6, IL-8, and SLPI were measured using ELISA. Linear regression with generalized estimating equations examined effects of cytokine concentrations on CVL HIV-1 RNA, adjusted for plasma HIV RNA, and measured coinfections. CVL IL-1β and IL-8 were significantly associated with CVL HIV-1 RNA. This persisted after adjusting for plasma HIV-1 RNA. Higher levels of IL-1β were associated with higher concentrations of HIV-1 RNA in CVL (β = 0.25, 95% CI 0.09, 0.42), as were higher levels of IL-8 (β = 0.34, 95% CI 0.17, 0.50). Adjusting for the presence of the coinfections described, this relationship was attenuated for IL-1β (β = 0.16; 95% CI –0.01, 0.33) but still significant for IL-8 (β = 0.29; 95% CI 0.13, 0.45). The proinflammatory cytokines IL-1β and IL-8 are associated with higher cervicovaginal HIV-1 RNA concentrations, even after controlling for plasma viral load and vaginal microbial cofactors. This association suggests that there may be additional, noninfectious causes of inflammation that increase cervicovaginal HIV-1 shedding.
doi:10.1089/aid.2010.0129
PMCID: PMC3034096  PMID: 20929397

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