Assessing the effects of multiple infections and long latency in the dynamics of tuberculosis

In order to achieve a better understanding of multiple infections and long latency in the dynamics of Mycobacterium tuberculosis infection, we analyze a simple model. Since backward bifurcation is well documented in the literature with respect to the model we are considering, our aim is to illustrate this behavior in terms of the range of variations of the model's parameters. We show that backward bifurcation disappears (and forward bifurcation occurs) if: (a) the latent period is shortened below a critical value; and (b) the rates of super-infection and re-infection are decreased. This result shows that among immunosuppressed individuals, super-infection and/or changes in the latent period could act to facilitate the onset of tuberculosis. When we decrease the incubation period below the critical value, we obtain the curve of the incidence of tuberculosis following forward bifurcation; however, this curve envelops that obtained from the backward bifurcation diagram.

Alternative management of diabetic ketoacidosis in a Brazilian pediatric emergency department

DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.

Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors

Abstract Background The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil. Methods A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses. Results The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient’s physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient’s physical activity was a significant correlate among physicians whereas assessing patient’s physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses. Conclusions Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.

Doenças respiratórias e fatores associados: estudo de base populacional em São Paulo, 2008-2009

OBJETIVO: Estimar a prevalência de bronquite aguda, rinite e sinusite em crianças e adolescentes e identificar fatores associados. MÉTODOS: Estudo transversal, de base populacional. Foi realizado inquérito domiciliar com 1.185 crianças e adolescentes de São Paulo, SP, de 2008 a 2009. Os participantes foram selecionados a partir de amostragem probabilística, estratificada por sexo e idade e por conglomerados em dois estágios. Para análise ajustada foi realizada regressão múltipla de Poisson. RESULTADOS: Dos entrevistados, 7,3% referiram bronquite aguda, 22,6% rinite e 15,3% sinusite. Após análise ajustada, associaram-se à bronquite aguda auto-referida: idade de zero a quatro anos (RP = 17,86; IC95%: 3,65;90,91), cinco a nove anos (RP = 37,04; IC95%: 8,13;166,67), dez a 14 anos (RP = 20,83; IC95%: 4,93;90,91), referir ter alergia (RP = 3,12; IC95%: 1,70;5,73), cor da pele preta/parda (RP = 2,29; IC95%: 1,21;4,35) e morar em domicílio com um a três cômodos (RP = 1,85; IC95%: 1,17;2,94); à rinite auto-referida: idade dez a 14 anos (RP = 2,77; IC95%: 1,60;4,78), 15 a 19 anos (RP = 2,58; IC95%: 1,52;4,39), referir ter alergia (RP = 4,32; IC95%: 2,79;6,70), referir ter asma (RP = 2,30; IC95%: 1,30;4,10) e morar em apartamento (RP = 1,70; IC95%: 1,06;2,73); à sinusite auto-referida: idade cinco a nove anos (RP = 2,44; IC95%: 1,09;5,43), dez a 14 anos (RP = 2,99; IC95%: 1,36;6,58), 15 a 19 anos (RP = 3,62; IC95%: 1,68;7,81), referir ter alergia (RP = 2,23; IC95%: 1,41;3,52) e apresentar obesidade (RP = 4,42; IC95%: 1,56;12,50). CONCLUSÕES: As doenças respiratórias foram mais prevalentes em grupos populacionais com características definidas, como grupo etário, doenças auto-referidas, tipo de moradia e obesidade.

Validation of models for predicting milk urea nitrogen concentrations, estimating dry matter intake by the NRC (2001)

The objective of this study was to validate three different models for predicting milk urea nitrogen using field conditions, attempting to evaluate the nutritional adequacy diets for dairy cows and prediction of nitrogen excreted to the environment. Observations (4,749) from 855 cows were used. Milk yield, body weight (BW), days in milk and parity were recorded on the milk sampling days. Milk was sampled monthly, for analysis of milk urea nitrogen (MUN), fat, protein, lactose and total solids concentration and somatic cells count. Individual dry matter intake was estimated using the NRC (2001). The three models studied were derived from a first one to predict urinary nitrogen (UN). Model 1 was MUN = UN/12.54, model 2 was MUN = UN/17.6 and model 3 was MUN = UN/(0.0259 × BW), adjusted by body weight effect. To evaluate models, they were tested for accuracy, precision and robustness. Despite being more accurate (mean bias = 0.94 mg/dL), model 2 was less precise (residual error = 4.50 mg/dL) than model 3 (mean bias = 1.41 and residual error = 4.11 mg/dL), while model 1 was the least accurate (mean bias = 6.94 mg/dL) and the least precise (residual error = 5.40 mg/dL). They were not robust, because they were influenced by almost all the variables studied. The three models for predicting milk urea nitrogen were different with respect to accuracy, precision and robustness.

Il sindacato della Corte di cassazione sul travisamento della prova

Sect. 606, par. 1, e), as modified by Law 46, enacted on Februray 20th, 2006 introduced the chance to appeal to the Court of cassation in case of inconsistent reasoning and extended control on its existence and on other flaws and lack of obvious logic over the text of the contested decision, namely “to other acts the process specified in the grounds of burden”. The renewed provision seems to properly reappoint the “distortion of the evidence”, i.e. the omitted or distorted evidence that could be relevant and conclusive one, in the peculiar context of the grounds' vice. After a general review of the obligation to state reasons for judicial decisions, we analyze the innovative status of the vice of “distortion of evidence” and the conditions and the limits - defined by the law - within we can contest a resolution for illegitimacy. Then, we outline the systematic spin-off brought by the new form of sect. 606, par. 1, e) on some institutions in the code of criminal procedure. Finally, we make the role of the Court of cassation clear in the modern criminal trial, since the 2006 reform gave no definite answer on this fundamental aspect of the question.

Chemical and physical properties of Amazonian aerosol particles

- ZUSAMMENFASSUNG:Die vorliegende Dissertation befasst sich mit der Bestimmung der chemischen und physikalischen Eigenschaften von Aerosolpartikeln im Amazonasbecken, die während Zeiten mit Biomasseverbrennung und bei Hintergrundbedingungen bestimmt wurden. Die Messungen wurden während zwei Kampagnen im Rahmen des europäischen Beitrags zum LBA-EUSTACH Experiment in Amazonien. Die Daten umfassen Messungen der Anzahlkonzentrationen, Größenverteilungen, optischen Eigenschaften sowie Elementzusammensetzungen und Kohlenstoffgehalte der gesammelten Aerosole. Die Zusammensetzung des Aerosols wies auf folgende drei Quellen hin: natürlichen biogenen, Mineralstaub, und pyrogenes Aerosol. Aller drei Komponenten trugen signifikant zur Extinktion des Sonnenlichts bei. Insgesamt ergab sich eine Steigerung der Meßwerte um ca. das Zehnfache während der Trockenzeit im Vergleich zur Regenzeit, was auf eine massive Einbringung von Rauchpartikeln im Submikrometerbereich in die Atmosphäre während der Trockenzeit zurückzuführen ist. Dementsprechend sank die Einzelstreualbedo von ca. 0,97 auf 0,91. Der Brechungsindex der Aerosolpartikel wurde mit einer neuen iterative Methoden, basierend auf der Mie-Theorie berechnet. Es ergaben sich durchschnittliche Werte von 1,42 – 0,006i für die Regenzeit und 1,41 – 0,013i für die Trockenperiode. Weitere klimatisch relevante Parameterergaben für Hintergrundaerosole und für Aerosole aus Biomasseverbrennung folgende Werte: Asymmetrieparameter von 0,63 ± 0,02 bzw. 0,70 ± 0,03 und Rückstreuungsverhältnisse von 0,12 ± 0,01 bzw. 0,08 ± 0,01. Diese Veränderungen haben das Potential, das regionale und globale Klima über die Variierung der Extinktion der Sonneneinstrahlung als auch der Wolkeneigenschaften zu beeinflussen.

Valutazione del rischio ecologico di residui di farmaci nell’ambiente: analisi sperimentale della tossicità sul crostaceo Daphnia magna

I farmaci sono una nuova classe di inquinanti ambientali ubiquitari che raggiungono, insieme alle acque fognarie, i depuratori urbani che non sono in grado di rimuoverli o degradarli. Così le acque depurate, ancora ricche di farmaci, si riversano nei canali riceventi portando questo carico di inquinanti fino ai fiumi e ai laghi. L’obiettivo del presente studio è stato fornire un contributo alla valutazione del rischio ecologico associato al rilascio di miscele di farmaci nell’ambiente acquatico, verificando con esperimenti di laboratorio gli effetti dell’esposizione congiunta a propranololo e fluoxetina sulla riproduzione di Daphnia magna, crostaceo planctonico d’acqua dolce. Il propranololo è un farmaco beta-bloccante, ossia blocca l'azione dell'adrenalina sui recettori adrenergici di tipo beta del cuore e viene utilizzato contro l’ipertensione. La fluoxetina è un antidepressivo, inibitore selettivo della ricaptazione della serotonina. Sono stati eseguiti test cronici (21 giorni) con solo propranololo (0,25 - 2,00 mg/L) e con solo fluoxetina (0,03 - 0,80 mg/L) che hanno stimato un EC50 per la riproduzione di 0,739 mg/L e di 0,238 mg/L, rispettivamente. L’ultima fase sperimentale consisteva in un test cronico con 25 miscele contenti percentuali diverse dei due farmaci (0%; 25%; 50%; 75%; 100%) e con diverse concentrazioni totali (0,50; 0,71; 1,00; 1,41; 2,00 unità tossiche). Le unità tossiche sono state calcolate sulla base degli EC50 dei precedenti test cronici con i singoli farmaci. I dati sperimentali del test sono stati analizzati utilizzando MixTox, un metodo statistico per la previsione degli effetti congiunti di miscele di sostanze tossiche, che ha permesso di stabilire quale fosse il modello in grado di rappresentare al meglio i risultati sperimentali. Il modello di riferimento utilizzato è stato la concentration addition (CA) a partire dal quale si è identificato il modello che meglio rappresenta l’interazione tra i due farmaci: antagonism (S/A) dose ratio dependent (DR). Infatti si evidenzia antagonismo per tutte le miscele dei due farmaci, ma più accentuato in presenza di una maggiore percentuale di propranololo. Contrariamente a quanto verificato in studi su altre specie e su effetti biologici diversi, è comunque stato possibile evidenziare un affetto avverso sulla riproduzione di D. magna solo a concentrazioni di propranololo e fluoxetina molto più elevate di quelle osservate nelle acque superficiali.

Meccanismi di produzione di energia in astrofisica

Prima di fornire una formulazione esaustiva dell'onda d'urto, è d'uopo definire il gas come oggetto fisico e le sue principali caratteristiche. Quanto si farà nei paragrafi seguenti quindi, sarà tentare di formalizzare il sistema gassoso dal punto di vista fisico e matematico. Sarà necessario introdurre un modello del sistema (par. 1.1) che ci permetta di lavorare a livello statistico sull'insieme di particelle che lo compongono per caratterizzare le funzioni termodinamiche classiche come medie temporali. Tramite queste considerazioni si stabilirà quali sono le quantità che si conservano nel moto di un fluido e si vedrà che tali leggi di conservazione formano un sistema di 5 equazioni differenziali parziali in 6 incognite. Tramite la linearizzazione di questo sistema si individueranno delle soluzioni chiamate onde sonore che danno un'indicazione sul modo in cui si propagano delle perturbazioni all'interno di un fluido; in particolar modo saranno utili per la determinazione del numero di Mach che rende possibile la distinzione tra due regimi: subsonico e supersonico (par. 1.2). Sarà possibile, a questo punto, indagare il fenomeno dell'onda d'urto (par. 2.1) e, nel dettaglio, due casi particolarmente utili in contesto astrofisico quali: l'onda d'urto per un gas politropico (par. 2.2), un'onda d'urto sferica che avanza verso il suo centro (2.2). Lo scopo di questa trattazione è indagare, o se non altro tentare, quanto avviene in un'esplosione di Supernova (par. 3). Relativamente a questo fenomeno, ne viene data una classificazione sommaria (par. 3.1), mentre particolare attenzione sarà rivolta alle Supernovae di tipo Ia (par. 3.2) che grazie alla loro luminosità standard costituiscono un punto di riferimento nell'Universo visibile.

Il principio di proporzionalità nella disciplina del mandato d'arresto europeo

Il presente lavoro affronta un tema di particolare attualità nella applicazione del mandato d’arresto europeo. Pensate per il contrasto alle forme più gravi di criminalità, le procedure di consegna hanno trovato sempre più spesso applicazione per vicende criminose di scarsa offensività, determinando conseguenze gravi sui diritti fondamentali degli individui coinvolti e mettendo a rischio la reciproca fiducia tra gli Stati membri nello spazio di libertà, sicurezza e giustizia. Ciò ha imposto alle istituzioni europee di richiamare gli Stati membri al rispetto del principio di proporzionalità, quale principio generale del diritto europeo. Il presente studio analizza i presupposti e le modalità di applicazione di tale principio, alla luce del nuovo assetto impresso all’Unione dal Trattato di Lisbona e nella prospettiva dei diritti fondamentali. In particolare, esso si sofferma sul ruolo da attribuire, rispetto allo specifico tema, alla Carta dei diritti fondamentali dell’Unione ed all’art. 52 par. 1 in essa previsto, ove emerge la valenza costituzionale del principio di proporzionalità.

Antiepileptic drugs and pregnancy. Population based pharmaco-epidemiological study on prescription patterns, pregnancy outcome and foetal health

Aims of the study: To assess the prevalence of Antiepileptic Drug (AED) exposure in pregnant women with or without epilepsy and the comparative risk of terminations of pregnancy (TOPs), spontaneous abortions, stillbirth, major congenital malformations (MCMs) and foetal growth retardation (FGR) following intrauterine AED exposure in the Emilia Romagna region (RER), Northern Italy (4 million inhabitants). Methods: Data were obtained from official regional registries: Certificate of Delivery Assistance, Hospital Discharge Card, reimbursed prescription databases and Registry of Congenital Malformations. We identified all the deliveries, hospitalized abortions and MCMs occurred between January 2009 and December 2011. Results: We identified 145,243 pregnancies: 111,284 deliveries (112,845 live births and 279 stillbirths), 16408 spontaneous abortions and 17551 TOPs. Six hundred and eleven pregnancies (0.42% 95% Cl: 0.39-0.46) were exposed to AEDs. Twenty-one per cent of pregnancies ended in TOP in the AED group vs 12% in the non-exposed (OR:2.24; CI 1.41-3.56). The rate of spontaneous abortions and stillbirth was comparable in the two groups. Three hundred fifty-three babies (0.31%, 95% CI: 0.28-0.35) were exposed to AEDs during the first trimester. The rate of MCMs was 2.3% in the AED group (2.2% in babies exposed to monotherapy and 3.1% in babies exposed to polytherapy) vs 2.0% in the non-exposed. The risk of FGR was 12.7 % in the exposed group compared to 10% in the non-exposed. Discussion and Conclusion: The prevalence of AED exposure in pregnancy in the RER was 0.42%. The rate of MCMs in children exposed to AEDs in utero was almost superimposable to the one of the non-exposed, however polytherapy carried a slightly increased risk . The rate of TOPs was significantly higher in the exposed women. Further studies are needed to clarify whether this high rate reflects a higher rate of MCMs detected prenatally or other more elusive reasons.

Vascularised fibula grafts for early tibia reconstruction in infants with congenital pseudarthrosis

Congenital pseudarthrosis of the tibia (CPT) is caused by an ill-defined, segmental disturbance of periosteal bone formation leading to spontaneous bowing, followed by fracture and subsequent pseudarthrosis in the first 2 years of life. The results of conventional treatment modalities (e.g., bracing, internal and external fixation and bone grafting) are associated with high failure rates in terms of persisting pseudarthrosis, malunion and impaired growth. As a more promising alternative, a more aggressive approach, including wide resection of the affected bone, reconstruction with free vascularised fibula grafts from the healthy contralateral leg and stable external fixation at a very early stage has been suggested. Between 1995 and 2007, 10 children (age 12-31 months, median 20 months) suffering from CPT were treated at our institutions according to this principle. Two patients were treated before a fracture had occurred. The length of the fibula graft was 7-9cm. End-to-end anastomoses were performed at the level of the distal tibia stump. The follow-up was 80 months (median, range 12 months to 12 years). Radiologic examination at 6 weeks postoperatively showed normal bone density and structure of the transplanted fibula in all cases and osseous consolidation at 19 of the 20 graft/tibia junctions. One nonunion was sucessfully treated with bone grafting and plate osteosynthesis. Pin-tract infection occurred in three patients. Five children sustained graft fractures that were successfully treated with internal or external fixation. Two patients developed diminished growth of the affected limb or foot; all others had equal limb length and shoe size. At long-term follow-up, tibialisation of the transplant had occurred, and normal gait and physical activities were possible in all children. We conclude that in spite of a relatively high complication rate and the reluctance to perform free flap surgery in infants at this young age, the present concept may successfully prevent the imminent severe sequelae associated with CPT.

Pooled analysis of trials comparing titanium-nitride-oxide-coated stents with paclitaxel-eluting stents in patients undergoing coronary stenting

We performed a pooled analysis of three trials comparing titanium-nitride-oxide-coated bioactive stents (BAS) with paclitaxel-eluting stents (PES) in 1,774 patients. All patients were followed for 12 months. The primary outcomes of interest were recurrent myocardial infarction (MI), death and target lesion revascularization (TLR). Secondary endpoints were stent thrombosis (ST) and major adverse cardiac events (MACE) including MI, death and TLR. There were 922 patients in the BAS group and 852 in the PES group. BAS significantly reduced the risk of recurrent MI (2.7% vs. 5.6%; risk ratio 0.50, 95% CI 0.31-0.81; p = 0.004) and MACE (8.9% vs. 12.6%; risk ratio 0.71, 95% CI 0.54-0.94; p = 0.02) during the 12 months of follow up. In contrast, the differences between BAS and PES were not statistically significant with respect to TLR (risk ratio 0.98, 95% CI 0.68-1.41), death (risk ratio 0.96, 95% CI 0.61-1.51) and definite ST (risk ratio 0.28, 95% CI 0.05-1.47). In conclusion, the results of this analysis suggest that BAS is effective in reducing TLR and improves clinical outcomes by reducing MI and MACE compared with PES.

All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study

Objective To examine all cause and disease specific mortality in patients with osteoarthritis of the knee or hip. Design Population based cohort study. Setting General practices in the southwest of England. Participants 1163 patients aged 35 years or over with symptoms and radiological confirmation of osteoarthritis of the knee or hip. Main outcome measures Age and sex standardised mortality ratios and multivariable hazard ratios of death after a median of 14 years’ follow-up. Results Patients with osteoarthritis had excess all cause mortality compared with the general population (standardised mortality ratio 1.55, 95% confidence interval 1.41 to 1.70). Excess mortality was observed for all disease specific causes of death but was particularly pronounced for cardiovascular (standardised mortality ratio 1.71, 1.49 to 1.98) and dementia associated mortality (1.99, 1.22 to 3.25). Mortality increased with increasing age (P for trend <0.001), male sex (adjusted hazard ratio 1.59, 1.30 to 1.96), self reported history of diabetes (1.95, 1.31 to 2.90), cancer (2.28, 1.50 to 3.47), cardiovascular disease (1.38, 1.12 to 1.71), and walking disability (1.48, 1.17 to 1.86). However, little evidence existed for increased mortality associated with previous joint replacement, obesity, depression, chronic inflammatory disease, eye disease, or presence of pain at baseline. The more severe the walking disability, the higher was the risk of death (P for trend <0.001). Conclusion Patients with osteoarthritis are at higher risk of death compared with the general population. History of diabetes, cancer, or cardiovascular disease and the presence of walking disability are major risk factors. Management of patients with osteoarthritis and walking disability should focus on effective treatment of cardiovascular risk factors and comorbidities, as well as on increasing physical activity.

Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis

Background Identifying modifiable factors that increase women's vulnerability to HIV is a critical step in developing effective female-initiated prevention interventions. The primary objective of this study was to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition. Methods and Findings We conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I2 values 0.0%–16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.18–1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00–1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01–1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio [OR] 1.24, 95% CI 1.04–1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p<0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p<0.001), respectively. Conclusions This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidated.