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  • About
  • The Global ETD Search service is a free service for researchers to find electronic theses and dissertations. This service is provided by the Networked Digital Library of Theses and Dissertations.
    Our metadata is collected from universities around the world. If you manage a university/consortium/country archive and want to be added, details can be found on the NDLTD website.
1

Desarrollo y validación de un método analítico para valoración de metronidazol, clotrimazol y lidocaína clorhidrato en óvulos vaginales, por cromatografía de líquidos (HPLC)

Chipana Paulino, Denis Danilo January 2016 (has links)
Se desarrolló una técnica analítica por cromatografía líquida de alta eficiencia para cuantificar los principios activos metronidazol, clotrimazol y lidocaína clorhidrato en óvulos vaginales, debido a que la técnica de análisis para este medicamento compuesto no se encuentra en libros oficiales. La técnica de análisis para los tres principios activos es realizada en dos sistemas cromatográficos diferentes, por lo que no pueden ser cuantificadas en un solo cromatograma, debido a la gran diferencia de sus concentraciones de los principios activos en los óvulos vaginales. Previamente a la validación se evaluó la aptitud del sistema. Los resultados fueron conformes a las especificaciones para un método cromatográfico recomendadas por la USP 38, comprobando que el equipo, el sistema electrónico, las operaciones analíticas y las muestras a analizar constituyen un sistema integral que puede evaluarse como tal. Para la validación se evaluaron los parámetros de desempeño de la técnica como son: Especificidad, Linealidad, Exactitud, Precisión, Robustez y Rango. El método desarrollado para metronidazol, clotrimazol y clorhidrato de lidocaína es específico porque identifica específicamente los 3 principios activos. Es lineal en el intervalo de concentración seleccionado (50% a 150% de la concentración teórica), con un coeficiente de correlación mayor de 0.995. Es exacto porque se obtuvieron porcentajes de recuperación entre 98% y 102%. Es preciso porque se obtuvieron coeficientes de variación menores a 2%. Es robusto (solo para el metronidazol) porque al realizar pequeñas modificaciones no es afectado por estos cambios. Los resultados de estos parámetros se sometieron a pruebas estadísticas demostrando que la técnica analítica propuesta para la cuantificación de los principios activos es especifica, exacta, precisa, robusta y lineal, así mismo, garantizando la confiabilidad de la nueva técnica. Palabras claves: metronidazol, clotrimazol, lidocaína clorhidrato, cromatografía líquida de alta eficiencia, validación, técnica analítica. / --- An analytical technique for high performance liquid chromatography to quantify the active ingredients metronidazole, clotrimazole and lidocaine hydrochloride, because the technique of analysis for the drug compound is not developed in official books. The analytical technique for the three substances is performed in two different chromatographic systems, so they cannot be quantified in a single chromatogram due to the large difference in the concentrations of active ingredients in vaginal ovules. Previously to the validation system suitability was evaluated. The results were in accordance with the specifications for a chromatographic method recommended by the USP 38, checking that the equipment, electronics, analytical operations and samples to be analyzed constitute an integral system that can be evaluated as such. To validate the performance parameters of the technique was evaluated as: Specificity, linearity, accuracy, precision, robustness and range. The method developed for metronidazole, clotrimazole, lidocaine hydrochloride is specific because it specifically identifies 3 active ingredients. It is linear over the range of selected concentrations (50% to 150% of the theoretical concentration), with a coefficient of correlation greater than 0.995. It is precisely because recovery rates between 98% and 102% were obtained. It is precision because the coefficients of variation were less than 2%. It is robust (for metronidazole alone) because making small changes is not affected by these changes. The results of these parameters are subjected to statistical tests showing that the analytical technique proposal for the quantification of the active ingredients is specified, accurate , precise , rugged and linear also ensuring the reliability of the new technique. Key words: metronidazole, clotrimazole, lidocaine hydrochloride, high performance liquid chromatography, validation, analytical technique.
2

Expressão dos genes Receptor Pregnano X (PXR), Citocromo P4503A (CYP3A) e resistência a multidrogas 1(MDR1) em fígado de peixe-zebra (Danio rerio)

Bresolin, Taise January 2005 (has links)
Dissertação (mestrado) - Universidade Federal de Santa Catarina, Centro de Ciências Biológicas. Programa de Pós-Graduação em Biotecnologia. / Made available in DSpace on 2013-07-16T00:52:55Z (GMT). No. of bitstreams: 1 213393.pdf: 956920 bytes, checksum: a810d760f276b24af6058e83ddf60604 (MD5) / O receptor pregnano X (PXR) é um receptor nuclear envolvido na regulação transcricional de enzimas envolvidas no metabolismo de fármacos e também de proteínas transportadoras. Em mamíferos, vários xenobióticos induzem a expressão dos genes do citocromo P4503A (CYP3A) e de resistência a multidrogas 1 (MDR1) através da via de sinalização do receptor PXR. Pouca atenção tem sido dada aos estudos sobre a identificação da função biológica dos homólogos do PXR em espécies de não-mamíferos. O peixe-zebra tem se tornado amplamente utilizado e aceito como espécie modelo em estudos toxicológicos e farmacológicos no entendimento dos mecanismos de doenças humanas e na identificação de vias de sinalização conservadas. O objetivo desse estudo foi avaliar a expressão in vivo dos genes PXR, CYP3A e MDR1 no fígado de peixes-zebra tratados com o esteróide sintético pregnenolona 16a-carboninitrilo (PCN), o antimicótico sintético clotrimazol (CTZ) e o composto fármaco nifedipina (NIF). Peixes (n=15 por grupo) foram expostos à PCN, CTZ e NIF (20 mg.Kg-1) por 48 horas. Os fígados foram retirados e utilizados para a extração do RNA total (n=5 por grupo). A partir do cDNA obtido foi realizada a reação de PCR, utilizando diferentes iniciadores para a amplificação de PXR, CYP3A, MDR1 e ß-ACTINA. Fígados de peixes tratados com PCN mostraram uma indução de 1,9 vezes na indução do PXR seguida de 1,8 vezes na indução do CYP3A e de 1,6 vezes na indução do MDR1 nos níveis de mRNA. CTZ e NIF não afetaram estatisticamente a expressão dos genes PXR, CYP3A e MDR1. O padrão similar na expressão do mRNA dos genes PXR, CYP3A e MDR1 encontrado em peixes tratados com diferentes indutores de PXR sugere que a associação intrínseca entre esses três genes é conservada no peixe-zebra.
3

Efeito de brassinosteroide no cerescimento, parametros bioquimicos e transporte de aminoacidos em plantas de Cajanus cajan (L.) Millsp, submetidas a estresse salino / Effect of brassinosteroid on growth, biochemical composition and transport of amino acids in plants-of Cajanus cajan (L.) Millsp, cultivated under salt stress

Dalio, Ronaldo Jose Durigan 12 July 2007 (has links)
Orientador: Claudia R. B. Haddad / Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-10T21:05:30Z (GMT). No. of bitstreams: 1 Dalio_RonaldoJoseDurigan_M.pdf: 923106 bytes, checksum: 4cfd1d62015260abdbf750e8baf62aa6 (MD5) Previous issue date: 2007 / Resumo: Plantas de Cajanus cajan receberam aplicações de brassinosteróide ou de clotrimazol (inibidor de síntese de brassinosteróides) e foram submetidas à salinidade. O objetivo deste trabalho foi verificar o efeito de duas concentrações de brassinosteróide (1 x 10-7 e 0,5 x 10-9 M) e uma de clotrimazol (1 x 10-4 M), no crescimento, composição bioquímica e transporte de aminoácidos em plantas de C. cajan, submetidas à duas concentrações de NaCl (200 e 400 mM). A salinidade afetou os parâmetros de crescimento (massas frescas e secas, comprimento da parte aérea e da maior raiz, número de folhas, área e suculência foliar), os parâmetros bioquímicos (teores de nitrato, prolina, aminoácidos livres, proteínas totais, açúcares solúveis, sacarose, clorofilas e carotenóides) e o padrão dos aminoácidos transportados. A proporção da maioria dos aminoácidos transportados no xilema diminuiu sob salinidade, com exceção de alanina e serina. A concentração de NaCl a 400 mM provocou as maiores alterações. A aplicação de clotrimazol mostrou-se eficiente na inibição dos efeitos provocados por brassinosteróide na grande maioria dos parâmetros estudados, sob salinidade. Não houve diferença em relação à eficiência das duas concentrações de brassinosteróide utilizadas na maioria dos parâmetros avaliados. A aplicação de brassinosteróide amenizou o efeito do estresse salino na maioria dos parâmetros de crescimento, dos parâmetros bioquímicos e no padrão de aminoácidos transportados em plantas de C. cajan, submetidas à salinidade / Abstract: Plants of Cajanus cajan received applications of brassinosteroid or clotrimazol (brassinosteroids synthesis inhibitor), and were subjected to salt stress. The goal of this study was to verify the effect of two concentrations of brassinosteroid (1.0 x 10-7and 0.5 x 10-9M), and one concentration of clotrimazol (1.0 x 10-4 M) on growth, biochemical composition and transport of amino acids in plants of C. Cajan, cultivated under two concentrations of NaCl (200 and 400 mM). The salt affected growth (fresh and dry mass, shoot length and main root length, number of leaves, leaf area and succulence of leaves) and biochemical parameters (nitrate, proline, free aminoacids, total protein, soluble sugars, sucrose, chlorophylls and carotenoids concentrations), and changed the pattern of amino acids transported. The proportion of most of the amino acids transported in the xylem was reduced by salinity. Alanine and serine were exceptions. The largest alterations were caused by 400 mM of NaCl. Clotrimazol was effective in inhibiting the effects caused by brassinosteroid for the great majority of studied parameters. There was no difference between the two concentrations of brassinosteroid for most parameters evaluated, under salinity. The application of brassinosteroid was effective diminishing the effect of salt on most of the growth and biochemical parameters, and in the patterns of amino acids transported in plants of C. Cajan subjected to salt stress / Mestrado / Mestre em Biologia Vegetal
4

Kapillarelektrophoretische Trennung und Quantifizierung von Aminoglykosiden und Clotrimazol / Separation and quantification of aminoglycosides and clotrimazole by means of capillary electrophoresis

Wienen, Frank January 2003 (has links) (PDF)
Im Rahmen dieser Arbeit wurden kapillarelektrophoretische Methoden entwickelt, mit denen es möglich ist, Gentamicinsulfat in Haupt- und Nebenkomponenten zu trennen. Ausgelöst wurden die Untersuchungen im Jahr 2000, da in den USA über 60 Patienten durch Gentamicin starben. Es wurde vermutet, dass dies auf Verunreinigungen in gewissen Chargen zurückzuführen ist. Gentamicin wird fermentativ aus Micromonospora purpurea gewonnen. Durch leichte Abweichungen im Herstellungsprozess können Produkte entstehen, die mit den bisher angewendeten Analysenmethoden nicht nachzuweisen sind. In der momentanen Arzneibuch-Monographie von Gentamicinsulfat wird zur Prüfung der verwandten Substanzen eine HPLC-Methode beschrieben, die Gentamicin ohne Derivatisierung mit einem gepulsten amperometrischen Detektor detektiert. Vorteil dieser Methode ist, dass Gentamicin nicht derivatisiert werden muss. Der große Nachteil dieser Methode ist aber, dass die einzelnen Peaks sehr lange Migrationszeiten haben (bis über 10 Minuten) und somit Verunreinigungen überdeckt werden können. Außerdem sind viele Bestandteile nicht von den Hauptkomponenten abgetrennt. Weiterhin ist diese Methode nicht sehr robust, da der Detektor sehr empfindlich ist. Eigene HPLC-Messungen an mehreren Gentamicin-Chargen zeigten die Probleme auf. Da Gentamicin kein chromophores System hat, kann es nicht mit einem UV/VIS-Detektor detektiert werden. Um dies dennoch zu ermöglichen, kann Gentamicin mit verschiedenen Reagenzien derivatisiert werden. In der vorliegenden Arbeit wurden alle Aminoglykoside mit ortho-Phthaldialdehyd und 2-Mercaptoessigsäure derivatisiert. Somit war eine Detektion bei 330 nm bzw. 340 nm möglich. Zur Trennung von Gentamicinsulfat wurde eine spezielle kapillarelektrophoretische Methode entwickelt. Die mizellare elektrokinetische Chromatographie (MEKC) ist nach Derivatisierung in der Lage, nahezu alle in der Monographie beschriebenen aber auch einige nicht aufgeführte Verunreinigungen zu trennen. Die Trennung erfolgt in einer Kieselgelkapillare mit einer Gesamtlänge von 33.0 cm, einer effektiven Länge von 24.5 cm und einem Innendurchmesser von 50 µm. Als Hintergrundelektrolyt wird ein Natriumtetraborat-Puffer verwendet (100 mM, pH 10.0), zu dem Desoxycholsäure-Natrium als mizellbildendes Reagenz in einer Konzentration von 20 mM und weiterhin beta-Cyclodextrin in einer Konzentration von 15 mM zugegeben wird. Die Proben werden hydrodynamisch bei 5000 Pa innerhalb 5 Sekunden auf der Anodenseite injiziert. Die Trennung erfolgt bei einer Kapillartemperatur von 25 °C und einer Trennspannung von +12 kV. Pikrinsäure wird als Interner Standard benutzt. Die Detektion erfolgt UV-spektroskopisch bei 340 nm. Die Hauptpeaks konnten durch „spiken“ mit den Einzelkomponenten, die u.a. säulenchromatographisch gewonnen wurden, identifiziert werden. Die vier Hauptkomponenten Gentamicin-C1, C1a, C2 und C2a sind basisliniengetrennt ebenso wie Gentamicin-C2b, die Verunreinigungen Garamin, Desoxystreptamin und Sisomicin. Bei den Untersuchungen von über 40 Gentamicin-Chargen verschiedener Hersteller und Händler fielen sowohl deutliche Unterschiede bezüglich der einzelnen Gehalte der Hauptkomponenten auf, als auch verschiedene Grade der Verunreinigungen. Anhand der Menge der Verunreinigungen konnten die Chargen in verschiedene Gruppen eingeteilt werden. Die Verunreinigung Sisomicin kann als Leitsubstanz der Verunreinigungen bezeichnet werden, da bei allen stärker verunreinigten Chargen Sisomicin in beträchtlichen Mengen vorhanden ist. Unter den untersuchten Proben befanden sich auch die Proben, die in den USA die eingangs erwähnten Todesfälle verursacht haben. Diese Proben konnten der Gruppe der stärker verunreinigten Gentamicin-Chargen eindeutig zugewiesen werden. Die Richtigkeit aller Messungen wurde durch 1H-NMR-Messungen bestätigt. Die Anwendbarkeit der entwickelten MEKC-Methode wurde auch an weiteren Aminoglykosiden untersucht. Die Methode ist ohne Änderung auf Sisomicin übertragbar. Der Sisomicin-Peak ist deutlich abgetrennt vom OPA-Reagenzpeak. Selbst kleine Verunreinigungen der CRS-Substanz können mit dieser Methode erkannt werden. Netilmicin und Amikacin können nicht ohne Änderungen mit der Methode vermessen werden, da sie unter diesen Bedingungen mit dem OPA-Peak komigrieren. Eine Anhebung der Trennspannung von +12 kV auf +14 kV lassen die Peaks hervortreten. Eine Unterscheidung der beiden Substanzen ist im Elektropherogramm nicht möglich, allerdings können sie durch 1H-NMR-spektroskopische Messungen identifiziert und unterschieden werden. Netilmicin wurde in vielen Gentamicin-Proben nachgewiesen. Bei Kanamycin liegen mit dieser Methode im Elektropherogramm sehr viele kleine Peaks sehr nahe beieinander. Durch Absenkung der Kapillartemperatur auf 20 °C können diese Peaks etwas besser getrennt werden... / The aim of this study was to separate gentamicin sulfate into its major and minor components by means of capillary electrophoresis. In May 2000 the death of 17 people and 60 people, respectively, was reported, following the administration of the commonly used broad spectrum antibiotic gentamicin sulfate. In addition hundreds of patients suffering from severe side effects were reported. Since this could not be explained by the pharmacological and toxicological properties of gentamicin, it was assumed that the side effects were related to impurities. Due to the fact that gentamicin is a fermentation product of Micromonospora purpurea, minor variations in the fermentation procedure may cause products, that cannot be detected by the analytical methods applied thus far. The current European Pharmacopoeia limits for related substance of gentamicin by means of an HPLC-method in combination with a pulsed amperometric detector. The advantage of this method is the fact, that it is not necessary to derivatize gentamicin. However, a major disadvantage of the method is the broadness of the main peaks (>10 minutes/peak). Hence, minor products could be covered by the main peaks. Furthermore, various peaks are not baseline separated and the method is not very robust owing to the highly sensitive detector. Due to the lack of a chromophore, gentamicin needs to be derivatized to allow detection by means of an UV-detector. In this study all aminoglycosides were labeled with orthophthaldialdehyde (OPA) in combination with 2-mercaptoacetic acid, which enabled detection at a wavelength of 340 nm. To separate gentamicin as OPA derivative, a method based on micellar electrokinetic chromatography (MEKC) was developed. This technique makes it possible to separate most of the impurities specified in the gentamicin monograph (garamine, deoxystreptamine, and sisomicin) and some additional, not further specified impurities such as paromamine and unknown products. The separation is carried out in a fused-silica capillary with a total length of 33.0 cm, an effective length of 24.5 cm and an inner diameter of 50 µm. Using sodium tetraborate buffer (100 mM, pH 10.0) as background electrolyte (BGE), deoxycholic acid sodium in a concentration of 20 mM as micelle forming agent and beta-cyclodextrin in a concentration of 15 mM are added. The samples are loaded hydrodynamically at 5000 Pa for 5 seconds on the anode side of the capillary and the separation is carried out at +12 kV and 25 °C. Picric acid is used as an internal standard and UV-detection is performed at 340 nm. Spiking experiments were performed using reference substances, obtained by column chromatography and commercially purchased reference substances for the impurities. The four major components gentamicin C1, C1a, C2, and C2a as well as the minor component C2b and the impurities garamine, deoxystreptamine, and sisomicin are baseline separated. Over 40 gentamicin batches of different pharmaceutical companies and producers were analyzed with respect to the content of the major components as well as the amount of the impurities. Varying levels of the major compounds as well as the impurities were identified, which allowed the grouping of the samples. All samples exhibiting a high amount of impurities were found to a high sisomicin concentration. Hence, sisomicin can be referred to as an impurity indicator. Some of the batches under scrutiny were responsible for the deaths found in the US. All these samples could be unambiguously assigned to the group which is characterized by a high number and a relatively high quantity of most unspecified impurities. All CE-measurements were verified by 1H NMR measurements. To investigate the applicability of the developed MEKC method, other aminoglycosides were also investigated. For sisomicin the standard method can be used without modification, since the sisomicin peak is separated from the OPA reagent peak and even small amounts of impurities of the CRS-substance can be detected with this method. For netilmicin and amikacin the developed method has to be modified. Under standard conditions the peaks of both substances co-migrates with the OPA reagent peak. Raising the voltage from +12 kV to +14 kV both peaks are separated. All Gentamicin samples were measured again using these new conditions. Netilmicin was often found in gentamicin samples. However, for these new conditions the migration time of netilmicin and amikacin are similar. Hence, they cannot be differentiated from each other in the same sample. Nevertheless, this differentiation can be carried out with 1H NMR measurements. Kanamycin samples show many peaks in a small zone of the electropherogram using the MEKC standard method. A slightly better separation can be obtained by using a lower temperature of the capillary of 20 °C instead of 25 °C...
5

DESENVOLVIMENTO DE FORMULAÇÕES NANOTECNOLÓGICAS PARA O TRATAMENTO DA CANDIDÍASE VULVOVAGINAL / DEVELOPMENT OF NANO-SCALE FORMULATIONS FOR THE TREATMENT OF VULVOVAGINAL CANDIDIASIS

Santos, Sara Saurin dos 21 August 2012 (has links)
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This work aimed the preparation of clotrimazole-loaded nanocapsule suspensions for vulvovaginal fungal infections treatment. For the first time, virgin coconut oil and medium chain triglycerides were used as an oil core of polymeric nanocapsules containing clotrimazole. The analytical method for quantification of this drug into nanoparticles was developed and validated. The method proved to be selective, linear, precise, accurate and robust. Using the method of interfacial deposition of preformed polymer, the nanoparticles were successfully prepared at three different concentrations of clotrimazole (1, 2 and 3 mg/mL). The physicochemical parameters measured were pH, particle diameter, polydispersity index, drug content, encapsulation efficiency, zeta potential and stability in storage during 60 days. The encapsulation efficiency was near to 100%, zeta potential was positive due to the cationic polymer employed, the pH was around 5.6 and drug contents were close to the theoretical values. The size distribution was nanometer (140-200 nm) with polydispersity index lower than 0.2. The formulations had adequate physicochemical characteristics and were stable during storage. Photodegradation studies have shown that the nanoencapsulation improved the stability of clotrimazole against UVC radiation compared to free drug solution after 14 hours of experiment. The in vitro drug release using the dialysis bag technique was characterized by a prolonged release. No burst effect was observed. Profilesare based on an anomalous transport and first order kinetics, regardless of the oil used. The in vitro microbiological test of nanocapsules suspensions was performed against Candida albicans and Candida glabrata susceptible and resistant to fluconazole by microdilution method. In combination with clotrimazole into nanoparticles, medium chain triglycerides was reported to have similar MICs of methanolic solution containing the oil and the drug. In addition to the antifungal activity in solution, coconut oil did not lose its activity after incorporation into the nanostructures and, in combination with drug, showed greater inhibition of microbial growth than the nanocapsules of medium chain triglycerides with clotrimazole. Finally nanoparticle suspensions were incorporated into hydrogels containing polymers with mucoadhesive properties, Pemulen® and Pullulan, which presented appropriate drug content, pH and spreadability. The formulations developed in this study represent promising alternatives for treatment of vulvovaginal candidiasis. / Este trabalho objetivou a preparação de suspensões de nanocápsulas contendo clotrimazol para o tratamento de infecções fúngicas vulvovaginais. Pela primeira vez, o óleo de coco virgem e os triglicerídeos de cadeia média foram empregados como núcleo oleoso de nanocápsulas poliméricas contendo clotrimazol. A metodologia analítica para a quantificação do fármaco nas nanopartículas foi desenvolvida e validada. O método mostrou-se seletivo, linear, preciso, exato e robusto. A partir do método de deposição interfacial do polímero pré-formado, as nanopartículas foram preparadas com sucesso em três concentrações diferentes de clotrimazol (1, 2 e 3 mg/mL). Os parâmetros físico-químicos avaliados foram pH, diâmetro de partícula, índice de polidispersão, teor, eficiência de encapsulamento, potencial zeta e estabilidade frente ao armazenamento por 60 dias. A eficiência de encapsulamento foi próxima a 100%, o valor do potencial zeta foi positivo devido ao polímero catiônico empregado, valor de pH em torno de 5,6 e teores de fármaco próximos aos teóricos. A distribuição de tamanho foi nanométrica (140-200 nm), com índice de polidispersão menor que 0,2. As formulações apresentaram características físico-químicas adequadas e foram estáveis durante o armazenamento. Estudos de fotodegradação mostraram que o nanoencapsulamento melhorou a estabilidade do clotrimazol sob radiação UVC, em comparação com a solução do fármaco livre, após 14 horas de experimento. A liberação do fármaco in vitro, a partir da técnica de sacos de diálise, foi caracterizada como uma liberação prolongada sem efeito burst, que foi mediada por transporte anômalo e seguiu cinética de primeira ordem, independente do óleo utilizado. As suspensões foram capazes de diminuir a velocidade de liberação do clotrimazol nas 24 horas de experimento. A partir do método de microdiluição, procedeu-se a avaliação microbiológica in vitro das suspensões de nanocápsulas contra Candida albicans e Candida glabrata sensíveis e resistentes ao fluconazol. Em combinação com o clotrimazol nas nanopartículas, os triglicerídeos de cadeia média apresentaram valores de CIMs semelhantes à solução metanólica contendo o óleo e o fármaco. Além de apresentar atividade antifúngica em solução, o óleo de coco não perdeu sua atividade após a incorporação na nanoestrutura e, em associação com o fármaco, apresentou maior inibição do crescimento microbiano do que as nanocápsulas de triglicerídeos de cadeia média com clotrimazol. Por fim, as suspensões nanoparticuladas foram incorporadas em hidrogéis contendo polímeros com propriedades mucoadesivas, Pemulen® e Pullulan, que apresentaram teor, pH e espalhabilidade adequados. As formulações desenvolvidas neste estudo representam alternativas promissoras para o tratamento da candidíase vulvovaginal.

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