Genital Symptoms Research Articles

Morbidity burden of imported chronic schistosomiasis among West African migrants

Past exposure to schistosomiasis is frequent among migrants from endemic countries, and chronic untreated infection may lead to long-term morbidities. We carried out a prospective population-based cross-sectional study among migrants from endemic Sub-Saharan countries living in Barcelona, Spain. Participants had not been previously diagnosed or treated for schistosomiasis. Clinical signs and symptoms were scrutinised through a systematic revision of electronic medical records and an on-site standardised questionnaire, and blood and urine samples were screened for Schistosoma. We recruited 522 eligible participants, 74.3% males, mean age 42.7 years (SD=11.5, range 18-76), Overall, 46.4% were from Senegal and 23.6% from Gambia. They had lived in the European Union for a median of 16 years (IQR 10-21). The prevalence of a Schistosoma-positive serology was 35.8%. S. haematobium eggs were observed in urine samples in 6 (1.2%) participants. The most prevalent symptoms among Schistosoma-positive participants were chronic abdominal pain (68.8%, OR=1.79; 95%CI 1.2-2.6), eosinophilia (44.9%, OR=2.69; 95%CI 1.8-4.0) and specific symptoms associated with urinary schistosomiasis, like self-reported episodes of haematuria (37.2%; OR=2.47; 95%CI 1.6-3.8), dysuria (47.9%, OR=1.84; 95%CI=1.3-2.7) and current renal insufficiency (13.4%; OR=2.35; 95%CI=1.3-4.3). We found a significant prevalence of gender-specific genital signs and symptoms among females (mainly menstrual disorders) and males (erectile dysfunction and pelvic pain). Individuals typically presented with a multitude of interconnected symptoms, most commonly chronic abdominal pain, which are often disregarded. Despite the lack of urine parasite identification, the high incidence of clinical signs and symptoms strongly correlated with a positive schistosomiasis serology suggests the existence of a heavy clinical burden among long-term West African migrants living for years/decades in the study region. More research is urgently required to determine whether these symptoms are the result of long-term sequelae or a persistent active Schistosoma infection.

Labial Fusion in a Postmenopausal Woman Presenting with Urinary Incontinence

ABSTRACT Genitourinary syndrome of menopause refers to the collection of signs and symptoms associated with decrease in estrogen and other sex steroids involving changes in labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder. This term was coined in 2014 to reduce the stigma associated with genital symptoms after menopause. Our patient is a 65-year-old woman, menopausal for the past 15 years, who presented with dribbling of urine for 1 month. On examination, she was diagnosed with complete labial fusion. Diabetes was incidentally detected and antidiabetic treatment was started. Considering dense labial adhesion, the patient underwent surgical separation of labia under anesthesia. Postoperatively, she was put on topical estrogen therapy and was advised to maintain proper hygiene. She was followed up regularly for a month to prevent refusion.

122 Monkeypox Correlations: Genital Symptoms, Immunocompromised Status and MSM

122 Monkeypox Correlations: Genital Symptoms, Immunocompromised Status and MSM

(042) IMMUNOSTAINING FOR MARKERS OF MAST CELLS AND NERVES IN BOTH EXCISED VESTIBULAR AND ENDOMETRIOSIS IMPLANT TISSUES IN A SINGLE PATIENT

Abstract Introduction Neuroproliferative vestibulodynia (NPV) is a chronic genital pain condition characterized by severe vestibular allodynia and hyperalgesia. The clinically suspected diagnosis of NPV is confirmed in excised vestibular tissue by immunohistochemical staining of > 8 cells per 100x magnification positively immunostained for CD 117, a mast cell marker, and 10 times the area compared to controls positively immunostained for PGP 9.5, a neuronal marker, Endometriosis, on the other hand, is a chronic pelvic pain condition associated with growth of ectopic endometrial-like tissue outside the uterus. The clinically suspected diagnosis is confirmed in excised endometriosis tissue revealing, in some patients, endometrial type glands and/or stroma. In patients with NPV and endometriosis, it is hypothesized that excess mast cells release cytokines and growth factors that promote neuroproliferation in their respective tissues, resulting in chronic genital and pelvic pain symptoms, respectively. In a study involving 65 patients with pathologically confirmed NPV, 63% reported having additional conditions associated with aberrant mast cell activity, including endometriosis. The conditions of NPV and endometriosis may both be focal to the vestibule and pelvis, respectively, but both may also share pathologies of aberrant mast cell activity with other systemic disorders. Objective To perform immunostaining for markers of mast cells and nerves in excised vestibular and endometriosis implant tissues from a single patient. Methods Fixed, paraffin-embedded vestibular tissue specimens from the 1:00-11:00 and 12:00 vestibule, and from excised endometriosis fibroadipose tissue on the rectosigmoid colon, were sectioned and immunostained for CD 117 (C-kit) and PGP 9.5. The immunostained slides were examined and digital photomicrographs taken. A minimum of 2 photomicrographs were examined at 100x magnification for each stained slide, identifying representative regions of the excised tissue. Manual counting of CD117 and PGP 9.5 immunopositive profiles, cells/nerves per 100x magnification, was performed for each photomicrograph. Results A 23-year-old woman presented with a history marked by painful and prolonged menstrual periods, inability to insert tampons, and discomfort with both entry and deep thrusting during intercourse. After excluding other forms of vestibulodynia, she underwent complete 1:00-11:00 and 12:00 subepithelial vestibulectomy with vaginal advancement flap reconstruction. Post-operatively, she reported “very much better” symptoms, with a reduction of entrance dyspareunia, but continued to experience deep thrusting pain with penetrative sexual activity. She subsequently underwent endometriosis excision surgery with positive lesions identified in 12 locations in the pelvis and retroperitoneum. Tissue stained for CD117 and PGP9.5 analyzed by manual counting exhibited > 20 immunopositive cells and nerves per 100x microscopic field in the epithelial basement membrane and adjacent subepithelial regions of the 1:00-11:00 and 12:00 vestibule, as well as in the endometriosis fibroadipose tissue on the rectosigmoid colon. Conclusions We report for the first time, in a single patient diagnosed with both NPV and endometriosis, immunostaining findings of high densities of mast cells and nerves in their respective tissues. These findings reinforce the hypothesis that NPV and endometriosis are linked to a broader condition associated with aberrant mast cell activity. Disclosure No.

(085) DAILY CHANGES IN GENITAL PAIN, NON-GENITAL PAIN, AND MOOD, AS PREDICTORS OF SEXUAL DESIRE AND SEX WITH PARTNER: THE ROLE OF POSITIVE MOOD AND THE NEED FOR A POSITIVE PSYCHOLOGY OF SEX

Abstract Introduction There is a lack of research using prospective daily reports to study the associations between genital pain, psychological state, and sexual function. Although many studies have examined the relations among these variables, the most common strategy used is one-time retrospective accounts, which are limited by recall bias and the inability to study day-to-day variations in these symptoms. Objective To examine how day-to-day changes in genital pain influence daily changes in negative mood, and how day-to-day changes in genital pain and psychological symptoms are associated with daily changes in sexual desire and having sex with a partner. Methods A sample of 258 women with genital pain completed daily surveys measuring pain symptoms, psychological state, and sexual desire and activity (n=5831 surveys total; M=20.6 surveys per participant). Daily reports of genital pain addressed pain intensity, duration, and type (continuous vs intermittent); daily reports of psychological state addressed feeling depressed, tense/on edge, happy, and attractive/beautiful; and daily reports of non-genital pain addressed headaches and cramps. Presence of menstruation was also queried. Multilevel analyses tested for effects of genital pain on negative mood; and for effects of all pain and psychological symptoms on sexual desire and sex with partner. Results Analyses presented in tables 1 and 2 consider only days when genital pain was present (3316 surveys; 57% of surveys). Analyses including days with no genital pain were also conducted, recoding pain intensity and duration as zero, and excluding pain type, with only minor changes in results which did not change the overall conclusions. Table 1 presents results from models testing for effects of genital pain on feeling depressed and feeling tense/on edge, and show that, controlling for random intercepts of individual participants, feeling depressed was significantly predicted by all three pain scores, whereas feeling tense/on edge was predicted only by pain intensity and duration. Table 2 presents results from models predicting sexual desire/libido and having sex with partner from all predictor variables while controlling for random intercepts of individual participants. Overall, the results from these models show that the strongest and most consistent predictors across the two outcomes were the psychological variables of feeling tense/on edge, feeling happy and feeling attractive. Feeling depressed had no effect on either outcome. Of the genital pain symptoms, only pain duration had an effect on desire, whereas both pain duration and intensity predicted sex with partner. Pain intensity showed a positive association with sex with partner, which likely reflects an increase in pain intensity after having sex. Conclusions The current findings illustrate the potential impact of genital pain on negative emotions, as well as the importance of positive mood (feeling happy and attractive) on sexual desire and activity. Whereas past research has often focused on negative affect as an outcome of genital pain1, and as a predictor of sexual function2, the present study suggests that we give more attention to positive mood and a positive psychology approach3 in addressing the link between genital pain and sexual function. Such an approach may also have broader implications for general wellness. Disclosure Yes, this is sponsored by industry/sponsor: Data was partially collected using the app “Vulvae”, which is a free-to-use app, and presents no conflict of interest for either of the authors. Clarification: No industry support in study design or execution.

Genital Self-Image and Body Dysmorphic Disorder Symptoms in Patients Undergoing Central Wedge vs. Linear Resection Labiaplasty: A Randomized Clinical Trial.

Labiaplasty, a surgical procedure designed to address labia minora hypertrophy, has been closely linked to the improvement of genital self-image and the alleviation of symptoms related to body dysmorphic disorder. Brazil stands as the global leader in the prevalence of labiaplasty procedures. This study aimed to assess alterations in genital self-image and symptoms of body dysmorphic disorder in individuals with labia minora hypertrophy who underwent either wedge or trim labiaplasty. A total of 48 adult women undergoing labiaplasty were enrolled in this randomized clinical trial with two parallel groups. Allocation ratio was 1:1. The Study Group (SG) underwent wedge labiaplasty, while the Control Group (CG) underwent trim labiaplasty. Genital self-image and symptoms of body dysmorphic disorder were assessed both preoperatively and six months postoperatively, using validated tools. After a six-month intervention period, a statistically significant improvement in genital self-image was observed (p<0.001), alongside a marked decrease in the score of symptoms related to body dysmorphic disorder (p<0.001). There were no significant differences in outcomes between the groups. Furthermore, no statistically significant associations were noted between complications and the specific technique employed. The study findings underscore the noteworthy improvement in genital self-image and a concurrent reduction in symptoms of body dysmorphic disorder, evident in both the wedge and linear labiaplasty groups at the six-month postoperative assessments. These results suggest that the choice of surgical technique does not significantly impact these outcomes.

Diagnosis of female genital schistosomiasis and other genital infections in young South African women: challenges in the syndromic approach

IntroductionFemale genital schistosomiasis is a common but neglected disease, which results in symptoms similar to sexually transmitted infections in Schistosoma haematobium-endemic areas of Africa and Middle East. In primary healthcare of low-income countries, healthcare professionals use syndromic management protocols for guidance when treating symptoms of genital infection, due to lack of laboratory resources. These protocols do not include treatment for female genital schistosomiasis, despite the overlap of symptoms. Women are at risk of not receiving the appropriate treatment. The aim of this study was to investigate challenges and missed opportunities when using syndromic management protocols for sexually transmitted infections in female genital schistosomiasis-endemic areas.MethodsThis is a secondary analysis of data from a large cross-sectional prevalence study conducted in 2011 in KwaZulu-Natal, South Africa. Young women in schistosomiasis-endemic areas were asked about genital symptoms and underwent laboratory testing and gynecological examinations to look for common genital infections including female genital schistosomiasis. We used the current South African syndromic management protocols as the basis and analyzed the associations between the reported genital symptoms and the differential diagnoses with logistic regression.ResultsBy use of the syndromic approach the conditions gonorrhea, trichomoniasis and herpes could be identified. The symptom “lower abdominal pain” was significantly associated with documented female genital schistosomiasis. However, the same association was not found with gonorrhea or chlamydia. We found no significant association between reported vaginal discharge syndrome and female genital schistosomiasis or between genital ulcer syndrome and female genital schistosomiasis.DiscussionFemale genital schistosomiasis frequently co-exists with, and mimics other genital infections in rural areas of Sub-Saharan Africa. The management protocols in schistosomiasis endemic countries should include advice on how to diagnose and manage this chronic, waterborne genital condition. There is an urgent need to upscale laboratory and diagnostic resources in low-and middle-income countries and specifically schistosomiasis-endemic areas, to diagnose these common genital infections more accurately and to treat affected women accordingly.

Minimum service package for the integration of female genital schistosomiasis in sexual and reproductive health services in Kenya

Female genital schistosomiasis (FGS) is caused by chronic Schistosoma hematobium infection. Over 56 million women and girls in sub-Saharan Africa are estimated to be infected with FGS. However, gaps in knowledge of the symptomatology of FGS often lead to misdiagnosis and undertreatment. FGS presents with nonspecific genital symptoms and is likely to be misdiagnosed as a sexually transmitted infection (STI). Recurrent treatment for STIs may result in marital discord, intimate partner violence, and social stigma. Other FGS complications include ectopic pregnancy, infertility, urine incontinence, 3-4-fold increased susceptibility to HIV infection, and persistence of human papillomavirus infection (HPV). A minimum service package (MSP) that is acceptable and feasible for the integration of FGS and sexual and reproductive health (SRH) services is needed. A foundational literature review was conducted to identify service points for FGS and sexual and reproductive health (SRH) service integration. The final MSP was developed through collaborative efforts with stakeholders in various fields associated with FGS and SRH services. The MSP identified four key areas for successful integration of FGS into SRH services including: health literacy, screening and diagnosis, treatment and care, and social inclusion and equity at the community and healthcare facility level. A context-specific integration MSP may be the most efficient, effective, and ethical way to comprehensively address the burden of FGS faced by women and girls in Africa.

The Effect of Pelvic Floor Muscle Training on Health-Related Quality of Life in Postmenopausal Women With Genitourinary Syndrome: A Systematic Review and Meta-Analysis.

Genitourinary syndrome is commonly reported in postmenopausal women. Kegel's exercise is a noninvasive therapy that improves pelvic floor muscle parameters. However, the effect of Kegel's exercise on health-related quality of life (HRQoL) in postmenopausal women with genitourinary syndrome has not been synthesized or shown. This study was designed to systematically review and analyze the previous literature to determine whether Kegel's exercise enhances HRQoL in postmenopausal women with genitourinary syndrome of menopause. A systematic review and meta-analysis of randomized controlled trials was conducted, and six databases were searched, including Embase, MEDLINE, Cochrane, CINAHL, Web of Science, and Scopus, from their dates of inception to November 2021. Eligible studies evaluated the effects of Kegel's exercise on HRQoL in postmenopausal women with urinary, sexual, or genital symptoms. Review Manager software was used to perform the meta-analysis using a random-effects model. Chi-square and I2 tests were used to evaluate heterogeneity among the studies. Meta-analysis was performed based on the symptoms (i.e., urinary, sexual, and genital) identified in the quality-of-life questionnaires. This systematic review covered five studies with 268 participants. The research appraisal found most of these studies had a low risk of bias. The intervention periods ranged from 4 to 12 weeks. Compared with non-Kegel's exercise or regular activity, Kegel's exercise was found to significantly improve HRQoL-related urinary symptoms (three studies, standardized mean difference = -0.95, 95% CI [-1.35, -0.54], I2 = 0%). However, the effect of this exercise on HRQoL-related sexual symptoms did not differ from non-Kegel's exercise or regular activity (two studies, standardized mean difference = 1.11, 95% CI [-0.25, 2.47], I2 = 94%). None of the covered studies examined the effect of Kegel's exercise on HRQoL-related genital symptoms. Kegel's exercise is an effective intervention for improving HRQoL-related urinary symptoms in postmenopausal women. However, there remains insufficient evidence to assess the effectiveness of Kegel's exercise on HRQoL-related genital symptoms in this population. The results support using Kegel's exercise as a useful intervention to manage urinary symptoms in postmenopausal women.

Clinical features and treatment outcomes of major depressive disorder with genital symptoms.

Clinical features and treatment outcomes of major depressive disorder with genital symptoms.

Genital Hygiene Behavior and its Relationship with Vaginitis

Purpose: To determine the relationship between genital hygiene behavior and the emergence of vaginitis,especially in female motorcycle taxi drivers at Jakarta areaPatients and methods: Subjects are 50 female motorcycle taxi drivers in Jakarta area who met inclusion/ exclusioncriteria. A questionnaire of genital hygiene behavior inventory (GHBI) was used to obtain the genital hygienebehavior among subjects. Vaginal examination and microbiological swab from vaginal discharge were thenperformed as diagnostic for any type of vaginitis. Data collected were then analyzed using SPSS application forunivariate and bivariate analysis to show subjects’ characteristics and to look for relationships between variables.Results: 62% of respondents are over 40 years old and most of them work more than 8 hours per day. Vaginitiswas found in 42% of drivers divided into 21 subjects with bacterial vaginosis (42%) and 8 subjects with vaginalcandidiasis (16%). There are more subjects with poor knowledge of general genital hygiene, menstrual hygienemanagement, and self-awareness of abnormal genital symptoms, but no statistically significant difference in theincidence of vaginitis and the total GHBI score (p&gt;0,05). This study found a relationship between age and theincidence of vaginitis in female motorcycle taxi drivers in Jakarta area.Conclusion: There is no relationship between the GHBI score, duration of work, length of working experience,access to clean toilet and the incidence of vaginitis. There is a significant relationship between age and the incidenceof vaginitis in female motorcycle taxi drivers.

P18 You can’t prescribe what you don’t have: the limitations of addressing the management of symptomatic sexually transmitted infections in a rural Zambian health post

Abstract Background Management of sexually transmitted infections (STIs) remains a significant global issue, with more than one million cases acquired each day worldwide.1 Growing antimicrobial resistance poses a significant threat to addressing this global burden of disease. While STIs are a recognized public health problem in Zambia,2 resistance remains largely an unknown entity.3 This is particularly true of rural areas where there is no local resistance data available and very few microbiology labs. In this setting, the WHO syndromic approach to STI management is recommended.4 Objectives To reduce inappropriate antimicrobial prescribing for genital presentations in a rural health post in Zambia by the provision of educational resources and collaborative teaching based on the WHO syndromic approach to STIs. Volunteers for a non-governmental organization designed and implemented a clinical audit to improve diagnosis and management of genital symptoms in a rural Zambian health post as part of an ongoing antimicrobial stewardship programme.5 Methods Antibiotic use was measured at two intervals over a 1 year period (April to June 2022 and January to March 2023). Patient records were reviewed against an inclusion criterion of a relevant genitourinary diagnosis. The data was analysed for diagnostic accuracy and for the appropriateness of antimicrobial prescribing using the appropriate prescribing ratio (APR).6,7 National guidelines and WHO recommended alternatives were used as the standard. Data collection and analysis was approved by the Zambian Ministry of Health. The WHO granted permission to use and adapt its materials (ID:202300108). The intervention consisted of collaborative teaching structured around the implementation of simple flow charts based on the WHO syndromic approach and national Zambian guidelines. One-to-one mentoring was delivered over a period of three weeks. Results The proportion of plausible differentials increased from 52.5% (n=40) to 80.5% (n=41). APR increased from 5% to 9.8%. The proportion of inadequate and unnecessary prescriptions reduced, falling from 85% to 73.2% and 10% to 2.4%, respectively. Suboptimal prescriptions increased, rising from 0% to 14.6%. Conclusions This audit supports the use of guidelines and education based around the WHO syndromic approach to improve the diagnosis of genital infections in low resource settings. The limited improvement in prescribing was most likely influenced by the severe antibiotic shortages reported by local healthcare workers.5 This highlights the significance of addressing supply chains and ordering processes, particularly to rural areas. It is likely that improvements in appropriate prescribing rates will depend on parallel improvements in local antimicrobial availability. No educational intervention can overcome an empty drug cupboard, but education can be used to conserve the limited stock through more selective use. Improved access to either laboratories or point of care testing would make the decision to prescribe easier. However, in their absence, increasing adherence to the WHO syndromic approach has the potential to limit unnecessary prescriptions in low-resource rural settings, improving resource conservation and antimicrobial stewardship.

Genitourinary Syndrome of Menopause: Does Everyone Have It?

In 2014, the North American Menopause Society and the International Society for the Study of Women's Sexual Health recommended using the term genitourinary syndrome of menopause (GSM) to cover a range of genital and urinary symptoms that might be experienced during and after menopause. The term as currently defined, however, includes symptoms that may not be menopausal symptoms. The term GSM also includes "objective" measures such as vaginal pH that do not relate to symptom severity and are not priorities for clinicians or patients. We question the validity of GSM as a new syndrome and recommend the definition of the syndrome be revised to ensure it more closely reflects the symptoms attributable to menopause and the experience, difficulties, and response to treatment of those affected.

Does genital herpes symptom history predict herpes simplex virus type 2 antibody positivity?

Sexually transmitted infections (STIs) associated with genital ulcer disease due to herpes simplex virus-2 (HSV-2) are a prominent cause of morbidity and mortality. Serologic screening for HSV-2 is recommended only for individuals with genital herpes symptom history. However, no validated symptom screening tool currently exists. Currently asymptomatic adults presenting for routine care at STI clinics in Lima, Peru completed a survey of prior genital herpes symptoms and received HSV-2 serological testing with the Euroimmun Anti-HSV-2 (gG2) ELISA IgG (Lubeck, Germany). A sub-sample of indeterminate results were sent for Western blot confirmatory testing. We assessed associations between past symptoms and anti-HSV-2 positivity and corrected the HSV-2 prevalence by re-classifying indeterminates per Western Blot results. We enrolled 131 participants between July and October 2022. HSV-2 antibody test results found 21.4% positive, 41.2% indeterminate, and 37.4% negative. Excluding indeterminate results, 36.4% were positive. Of participants with no prior symptoms 31.2% tested positive, compared to 35.7% with one prior symptom, 50.0% with 2, and 50.0% with 3+ prior symptoms. Among the sub-sample of indeterminates, 92.6% were confirmed positive by Western Blot, bringing the total estimated proportion of participants with HSV-2 antibodies to 59.5%. Either based on the original classification of HSV-2 antibody status or after incorporation of confirmatory testing results, there was no significant association between symptom history and HSV-2 antibody positivity. With currently available tests, recommendations to screen individuals based on genital herpes symptom history may not be useful. More discriminatory symptom screening tools or HSV-2 antibody tests with better performance are needed.

Efficacy and safety of apremilast in patients with moderate-to-severe genital psoriasis: Results from DISCREET, a phase 3 randomized, double-blind, placebo-controlled trial

Genital psoriasis can be stigmatizing, is highly prevalent among patients with psoriasis, and has limited treatment options. Apremilast is a unique oral immunomodulating phosphodiesterase 4 inhibitor approved for psoriasis treatment. To assess the efficacy and safety of apremilast 30mg twice daily in patients with genital psoriasis. DISCREET, a phase 3, placebo-controlled trial (NCT03777436), randomized patients with moderate-to-severe genital psoriasis (stratified by affected body surface area <10% or ≥10%) to apremilast or placebo for a 16-week period, followed by an apremilast extension period. Week 16 results are presented. Patients were randomized to apremilast (n=143) or placebo (n=146). At Week 16, 39.6% and 19.5% of apremilast and placebo patients, respectively, achieved a modified static Physician Global Assessment of Genitalia response (primary endpoint; score of 0/1, ≥2-point reduction); treatment difference was significant (20.1%, P=.0003). Improvements in genital signs and symptoms, skin involvement, and quality of life were observed. Common treatment-emergent adverse events were diarrhea, headache, nausea, and nasopharyngitis. Lack of active-comparator. Apremilast demonstrated statistically and clinically meaningful genital Physician Global Assessment responses and improvement of signs, symptoms, severity, and quality of life in this first randomized, controlled study of an oral systemic treatment in patients with genital psoriasis.

Towards Outcome-Driven Patient Subgroups: A Machine Learning Analysis Across Six Depression Treatment Studies

BackgroundMajor depressive disorder (MDD) is a heterogeneous condition; multiple underlying neurobiological and behavioral substrates are associated with treatment response variability. Understanding the sources of this variability and predicting outcomes has been elusive. Machine learning (ML) shows promise in predicting treatment response in MDD, but its application is limited by challenges to the clinical interpretability of ML models, and clinicians often lack confidence in model results. In order to improve the interpretability of ML models in clinical practice, our goal was to demonstrate the derivation of treatment-relevant patient profiles comprised of clinical and demographic information using a novel ML approach. MethodsWe analyzed data from six clinical trials of pharmacological treatment for depression (total n = 5438) using the Differential Prototypes Neural Network (DPNN), a ML model that derives patient prototypes which can be used to derive treatment-relevant patient clusters while learning to generate probabilities for differential treatment response. A model classifying remission and outputting individual remission probabilities for five first-line monotherapies and three combination treatments was trained using clinical and demographic data. Prototypes were evaluated for interpretability by assessing differences in feature distributions (e.g. age, sex, symptom severity) and treatment-specific outcomes. ResultsA 3-prototype model achieved an area under the receiver operating curve of 0.66 and an expected absolute improvement in remission rate for those receiving the best predicted treatment of 6.5% (relative improvement of 15.6%) compared to the population remission rate. We identified three treatment-relevant patient clusters. Cluster A patients tended to be younger, to have increased levels of fatigue, and more severe symptoms. Cluster B patients tended to be older, female, have less severe symptoms, and the highest remission rates. Cluster C patients had more severe symptoms, lower remission rates, more psychomotor agitation, more intense suicidal ideation, and more somatic genital symptoms. ConclusionIt is possible to produce novel treatment-relevant patient profiles using ML models; doing so may improve interpretability of ML models and the quality of precision medicine treatments for MDD.

Prevalence of Ureaplasma urealyticum, Mycoplasma hominis and Chlamydia trachomatis in symptomatic and asymptomatic patients.

The purpose of the present study was to assess the prevalence of Ureaplasma urealyticum (U. urealyticum), Mycoplasma hominis (M. hominis) and Chlamydia trachomatis (C. trachomatis) in a Romanian population considering the presence or absence of genital symptoms. Urethral and vaginal samples were collected from patients presenting at 'Ponderas' Academic Hospital (Bucharest, Romania) from January 2021 to December 2021. A total of 266 samples were obtained from two groups of patients: Symptomatic subjects with urethritis, prostatitis, vaginitis or both urethritis and prostatitis (n=59; 22%), and asymptomatic subjects (n=207; 78%). Mycoplasma and Chlamydia kits were used to assess the presence of U. urealyticum and M. hominis, and C. trachomatis, respectively. The symptomatic subjects comprised 27 patients with urethritis symptoms, of whom 4 (15%) were infected with U. urealyticum and 1 (4%) was infected with C. trachomatis. In addition, 23 (9%) of the patients had prostatitis-like symptoms, which in 3 (13%) of the patients was associated with U. urealyticum and in 1 patient (4%) was associated with C. trachomatis. None of the symptomatic patients were infected with M. hominis. By contrast, 29 (14%) of the asymptomatic patients were discovered to be infected with U. urealyticum, 13 (6%) were coinfected with both Mollicutes and 4 (2%) were infected with C. trachomatis; only 1 patient was positive for M. hominis alone. Two patients (14%) who presented with U. urealyticum and M. hominis coinfection were also infected with C. trachomatis. No patient with U. urealyticum or M. hominis alone was also positive for C. trachomatis. Therefore, the most frequently identified pathogen populating the genital tract in both males and females was U. urealyticum, followed by coinfection with U. urealyticum and M. hominis, and C. trachomatis. As these infections are asymptomatic in numerous cases, this suggests that a thorough screening should be mandatory.

Evaluation and optimization of the syndromic management of female genital tract infections in Nairobi, Kenya

BackgroundGenital tract infections pose a public health concern. In many low-middle-income countries, symptom-based algorithms guide treatment decisions. Advantages notwithstanding, this strategy has important limitations. We aimed to determine the infections causing lower genital tract symptoms in women, evaluated the Kenyan syndromic treatment algorithm for vaginal discharge, and proposed an improved algorithm.MethodsThis cross-sectional study included symptomatic non-pregnant adult women presenting with lower genital tract symptoms at seven outpatient health facilities in Nairobi. Clinical, socio-demographic information and vaginal swabs microbiological tests were obtained. Multivariate logistic regression analyses were performed to find predictive factors for the genital infections and used to develop an alternative vaginal discharge treatment algorithm (using 60% of the dataset). The other 40% of data was used to assess the performance of each algorithm compared to laboratory diagnosis.ResultsOf 813 women, 66% had an infection (vulvovaginal candidiasis 40%, bacterial vaginosis 17%, Neisseria gonorrhoea 14%, multiple infections 23%); 56% of women reported ≥ 3 lower genital tract symptoms episodes in the preceding 12 months. Vulvovaginal itch predicted vulvovaginal candidiasis (odds ratio (OR) 2.20, 95% CI 1.40–3.46); foul-smelling vaginal discharge predicted bacterial vaginosis (OR 3.63, 95% CI 2.17–6.07), and sexually transmitted infection (Neisseria gonorrhoea, Trichomonas vaginalis, Chlamydia trachomatis, Mycoplasma genitalium) (OR 1.64, 95% CI 1.06–2.55). Additionally, lower abdominal pain (OR 1.73, 95% CI 1.07–2.79) predicted sexually transmitted infection. Inappropriate treatment was 117% and 75% by the current and alternative algorithms respectively. Treatment specificity for bacterial vaginosis/Trichomonas vaginalis was 27% and 82% by the current and alternative algorithms, respectively. Performance by other parameters was poor to moderate and comparable between the two algorithms.ConclusionSingle and multiple genital infections are common among women presenting with lower genital tract symptoms at outpatient clinics in Nairobi. The conventional vaginal discharge treatment algorithm performed poorly, while the alternative algorithm achieved only modest improvement. For optimal care of vaginal discharge syndrome, we recommend the inclusion of point-of-care diagnostics in the flowcharts.

Ectopic insulinoma: a systematic review.

Knowledge of ectopic insulinomas comes from single cases. We performed a systematic review through PubMed, Web of Science, Embase, eLibrary and ScienceDirect of all cases reported in the last four decades. We also describe one unreported patient. From 28 patients with ectopic insulinoma, 78.6% were female and mean age was 55.7 ± 19.2 years. Hypoglycaemia was the first symptom in 85.7% while 14.3% complained of abdominal pain or genital symptoms. Median tumour diameter was 27.5 [15-52.5] mm and it was localised by CT (73.1%), MRI (88.9%), [68Ga]Ga-DOTA-exedin-4 PET/CT (100%), 68Ga-labelled-DOTA-conjugated somatostatin analogue PET/TC (100%), somatostatin receptor scintigraphy (40%) and endoscopic ultrasound (50%). Ectopic insulinomas were located at duodenum (n = 3), jejunum (n = 2), and one respectively at stomach, liver, appendix, rectum, mesentery, ligament of Treitz, gastrosplenic ligament, hepatoduodenal ligament and splenic hilum. Seven insulinomas were affecting the female reproductive organs: ovary (n = 5), cervix (n = 2) and remaining tumours were at retroperitoneum (n = 3), kidney (n = 2), spleen (n = 1) and pelvis (n = 1). 89.3% underwent surgery (66.7% surgery vs. 33.3% laparoscopy) and 16% underwent an ineffective pancreatectomy. 85.7% had localized disease at diagnosis and 14.3% developed distant metastasis. Median follow-up time was 14.5 [4.5-35.5] months and mortality was reported in 28.6% with median time until death of 60 [5-144] months. In conclusion, ectopic insulinomas are presented as hypoglycaemia with female preponderance. Functional imaging [68Ga]Ga-DOTA-exedin-4 PET/CT and 68Ga-labelled-DOTA-conjugated somatostatin analogue PET/TC have very high sensitivity. Clinicians should be alert to the possibility of extra-pancreatic insulinomas when classic diagnostic tests and intraoperative pancreas exploration failed to locate the tumour.

Labiaplasty in Asian women: Motivation, technique feasibility, and patient reported outcomes

Labiaplasty is an increasingly popular aesthetic procedure. However, there is a lack of information regarding different surgical procedures and Asian patients' motivations and outcomes. This study aimed to understand patients' motivations for seeking labiaplasty and to examine surgical outcomes of different procedures. This retrospective study enroled patients between August 2016 and May 2021. Patient demographics, surgical procedures, complications, and revision surgeries were reviewed. Responses to questionnaires regarding patient motivations for undergoing labiaplasty, pre- and postoperative discomfort and aesthetics, Rosen's Self-Esteem Scale (RSES) scores, and Female Genital Self-Image Scale (FGSIS) scores were recorded. One hundred thirty-one patients were included, with an average age of 30.3±7.78 years. Eighty-seven (66.4%) patients underwent bilateral labiaplasty, and 44 (33.6%) underwent unilateral labiaplasty. The surgical techniques included 61 (46.6%) direct resections, 50 (38.2%) wedge resections, and 20 (15.3%) "hockey stick" procedures. Wound dehiscence occurred in 37 (28.2%) patients. A significant increase in complications occurred after the hockey stick procedure and wedge resection. Patients' motivation for surgery included aesthetic reasons in 62.0%, symptom relief in 91.5%, and repeated infection in 4.2%. There was a significant difference between pre- and postoperative genital aesthetics (p0.001) and discomfort symptoms (p0.001). The average RSES score was 19.68±4.03, and the average FGSIS score was 20.77±3.20. Pain and discomfort remained the most important motivations for Asian women to seek labiaplasty, followed by aesthetic reasons. With good preoperative consultation and surgical planning, satisfaction can be achieved concerning functional and aesthetic aspects.