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Pelvic inflammatory disease (PID) is a spectrum of disorders and can be a serious infection in the upper genital tract/reproductive organs (uterus, fallopian tubes, and ovaries) and includes any single or combination of endometritis, tubo-ovarian abscess, and salpingitis. PID can be sexually transmitted or naturally occurring, has the highest incidence in ages 15–25, and is the leading cause of infertility in women [ 218 ] ( http://www.ashasexualhealth.org/stdsstis/pid/ ).

PID can be clinically difficult to identify when patients present with mild or nonspecific symptoms. Finding symptoms on physical examination (cervical motion tenderness) as well as other criteria (elevated temperature or mucopurulent discharge) increases the specificity and positive predictive value of laboratory tests. Diagnostic tests are dependent on the clinical severity of disease, epidemiological risk assessment, and whether invasive procedures, such as laparoscopy and/or endometrial biopsy, are used. Bacterial tests performed on non–aseptically collected specimens (endocervical or dilatation and curettage) have limited utility in diagnosing PID. Actinomyces spp are part of normal flora and can often be seen on Pap smears. While Actinomyces spp have been associated with intrauterine devices (IUDs) in the past, they are very uncommon and usually occur most commonly in 2 settings: if a patient has an infection at the time of insertion of an IUD and if the IUD is left in place past the recommended time of removal (typically 5 years) [ 219 ]. If Actinomyces infection is suspected, the laboratory should be notified to culture such samples anaerobically, including an anaerobic broth that is held for ≥5 days. Patients with suspected PID should be tested for CT, GC, and HIV. Both difficulty in diagnosis as well as significant potential sequelae should make the threshold for therapy low [ 220 ].

Postpartum endometritis should be suspected when the patient presents with high fever (≥101°F [38.3°C] or >100.4°F [38.0°C] on >2 occasions >6 hours apart after the first 24 hours of delivery and up to 10 days postdelivery), abdominal pain, uterine tenderness, and foul lochia. Usually a multiorganism syndrome, the infection is most commonly seen in patients with unplanned cesarean delivery because of the inability to introduce antibiotics quickly. Postpartum endometritis can be reduced by testing and treating for symptomatic BV late in pregnancy, which has been associated with preterm labor and prolonged delivery. Late postpartum endometritis suggests possible chlamydia or other chronic STI.

Although the role of culture in the setting of endometritis is controversial, diagnostic tests to consider in the diagnosis of PID and postpartum endometritis are shown in Table 40 .

Table 40.

Laboratory Diagnosis for Pathogens Associated With Pelvic Inflammatory Disease and Endometritis

Abbreviations: EIA, enzyme immunoassay; HIV, human immunodeficiency virus; NAAT, nucleic acid amplification test; PID, pelvic inflammatory disease; RT, room temperature.

spp are an uncommon cause of PID.

Gram stain may aid in identification of significant pathogen.

Limited identification and antimicrobial susceptibility testing when cultures show multiple mixed aerobic and anaerobic organisms.

Invasive specimens obtained by laparoscopic or other sterile technique.

In patients with late-appearing postpartum endometritis, consider chronic and/or asymptomatic sexually transmitted infections such as chlamydia.

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Table 40.

Laboratory Diagnosis for Pathogens Associated With Pelvic Inflammatory Disease and Endometritis

Abbreviations: EIA, enzyme immunoassay; HIV, human immunodeficiency virus; NAAT, nucleic acid amplification test; PID, pelvic inflammatory disease; RT, room temperature.

spp are an uncommon cause of PID.

Gram stain may aid in identification of significant pathogen.

Limited identification and antimicrobial susceptibility testing when cultures show multiple mixed aerobic and anaerobic organisms.

Invasive specimens obtained by laparoscopic or other sterile technique.

In patients with late-appearing postpartum endometritis, consider chronic and/or asymptomatic sexually transmitted infections such as chlamydia.

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Children for whom sexual assault is a consideration should be referred to a setting or clinic that specifically deals with this situation. Readers are referred to the references by Girardet et al and the 2015 CDC guidelines, where NAAT and noninvasive specimens have yielded excellent results [ 195 , 221 ].

Sites 4, 13, 14, 18 and 19 contained individuals with mtDNA haplotypes from but the nuclear genome entirely from the other species. Jin . provided evidence that from the Qiadam Basin exhibited a rapid eastward range expansion as the Yellow River drained the paleao-Lake Gonghe, approximately 0.15 million years ago [ 39 ]. Under this scenario, would have come into secondary contact with populations isolated during this time. Hybridization would have resulted in introgression of mtDNA haplotypes from both of these species. Continual backcrossing with one parental species would have "diluted" any evidence of hybridization in their nuclear genomes, while the introgressed mitochondrial genome remained in place. Indeed, historical hybridization and introgression of mtDNA haplotypes has been reported in a number of studies ranging from amphibians to mammals [ 49 , 50 , Sleeveless Top Sugarloaf by VIDA VIDA Cheap Sale Best Prices Cheap Very Cheap Sg2Vim
]. For example, Melo-Ferreira . reported extensive introgression in the Iberian Hares from Spain with 32% of containing an mtDNA lineage from [ 49 ].

Our genetic clustering did not match the morphological diagnosis provided by Wang . [ 35 ], although the distribution of the genetic clusters was largely congruent with their proposed species ranges. Wang . suggested that has a tail length larger than its snout-vent length and has more than 100 rows of back scales, while has a relatively short tail and fewer than 100 rows of back scales [ 35 ]. Approximately half of identified in this study did not possess these "diagnostic" characters. This is not particularly surprising given that the genus is notorious for exhibiting large intraspecific morphological variation but lack of consistent interspecific differences [ JEWELLERY Necklaces Almala Cheap Low Price Wide Range Of Sale Online Je5DxR4X8S
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]. Such phenotypic diversity has made it particularly difficult to delineate species and morphology-based taxonomy is very confusing in this genus. For example, more than ten names have been applied to historically [ 38 ]. Rather than searching for a few diagnostic characters, a multivariate analysis, such as principle component analysis, may be more appropriate to dissect the morphological differences between and . It is important to note that a lack of congruence between morphology and other tools (e.g. genetic) for diagnosing species should not necessarily be regarded as evidence against the validity of two species [ 8 ]. Traditional morphology-based taxonomy, is only one way to describe "life's diversity" and species hypotheses developed based on morphology alone should be tested using different approaches with a variety of data sets [ 8 ]. Wang . also described chromosomal differences between the two species; while has ZW sex chromosomes, lacks identifiable sex chromosomes [ 35 ]. Unfortunately, we do not have chromosome data for specimens examined in this study. Nevertheless, the chromosome difference could potentially provide a reproductive isolation mechanism.

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