Drug eruptions and the vulva.

Drug reactions affecting the vulva are understudied and underreported, with some having the potential to cause serious morbidity through long-term sequelae. We conducted a literature review to investigate the current evidence about vulval drug eruptions. We aimed to establish the extent of drug reactions affecting the vulva, identify the common culprit drugs, and review current evidence and guidelines regarding their management. The vulval involvement seen in Steven-Johnson syndrome, toxic epidermal necrolysis and fixed drug eruption forms the focus of this review, but we also summarize the current evidence regarding less common reactions.

Nocturnal Vulval Pain in Girls-A Subset of Vulvodynia?

OBJECTIVES: The aims of the authors' case series were to outline the clinical features of prepubertal nocturnal vulval pain syndrome and to look at management and outcomes. METHODS: Clinical details of prepubertal girls experiencing episodes of nocturnal vulval pain with no identifiable cause were recorded and analyzed. Parents completed a questionnaire to look at outcomes. RESULTS: Eight girls with age at onset of symptoms between 3.5 and 8 years (mean 4.4 years) were included. Each patient described intermittent episodes of vulval pain lasting between 20 minutes and 5 hours, starting 1-4 hours after falling asleep. They were crying and rubbing or holding the vulva with no obvious cause seen. Many were not fully awake and 75% had no recollection of the events. Management focused on reassurance alone. The questionnaire showed that 83% had full resolution of symptoms with a mean duration of 5.7 years. CONCLUSIONS: Prepubertal nocturnal vulval pain syndrome may be a subset of vulvodynia (generalized, spontaneous, intermittent) to be included in the clinical spectrum of night terrors. Recognizing the clinical key features should aid prompt diagnosis and reassurance of the parents.

Vulvar Lichen Planus Presenting as Chronic Vulvar Purpura.

Background: There is a broad spectrum of vulvar pigmented lesions that differ based on their histopathological and clinical features. Chronic vulvar purpura is a rare entity, associated with a broad morphological spectrum, from lichen aureus, Zoon's vulvitis, pigmented purpuric dermatosis and with lichen planus as in our case. Case presentation: In this article we discuss a case of an 86-year-old white woman with hyperpigmentation on her upper vulva, next to the introitus, with complaints of urine incontinence. Biopsy revealed subepithelial stromal lichenoid inflammatory infiltrate containing plasma cells, lymphocytes and some neutrophilic granulocytes as well as dilated and congested vessels. Hemosiderin deposits and erythrocyte extravasation were found. There was evidence of hyperkeratosis with hyper granulosis and erosions. Spongiosis was also noted. Few melanocytes were identified with no sign of malignancy. These findings correlate with the diagnosis of vulvar lichen planus. Conclusions: Chronic vulvar purpura is a clinical term used for different chronic inflammatory dermatoses presenting as red bluish or violaceous discolorations on the vulva, often associated with cayenne-pepper-like speckling. Considering a great overlap of possible diseases, the final diagnosis could be challenging. It is important to exclude a melanocytic tumour in these cases.

A framework for involving coproduction partners in research about young people with type 1 diabetes.

BACKGROUND: Involvement of end-users in research can enhance its quality, relevance, credibility and legitimacy; however, the processes through which these changes occur are unclear. Our aim was to explore a coproduction research team's experiences of their involvement in research about young people with type 1 diabetes mellitus (T1DM). METHODS: Semi-structured interviews conducted with two young people with T1DM, two parents, one diabetes educator, one endocrinologist-scientist and one research-engineer explored experiences of coproduction research and its impact on both the research and the participants. Drawing on grounded theory, we undertook inductive analysis and storyline mapping to develop a theorized framework of mechanisms supporting the process of coproduction in T1DM research with young people. FINDINGS: The framework involving coproduction partners in research about young people with type 1 diabetes centres on the unique expertize that different team members bring to the research and describes conditions that enable expert contributions through the enactment of a variety of expert roles. The framework also describes outcomes-the impact of the expert contributions on both the research and the team members involved. CONCLUSION: The findings of this small exploratory study provide a sound foundation to develop further understanding about structures and processes that are integral for the success of coproduction research teams. The framework may provide a guide for researchers planning to incorporate coproduction, on elements that are important for this model of research to succeed. It may also inform coproduction impact assessment research and be used for hypothesis testing and expansion in future studies.

"I Have Failed Them and Failed My Duties": Experiences of Hospital Social Workers Discharging Patients into Homelessness.

Homelessness is a long-standing issue at the forefront of healthcare globally, and discharge of homeless patients from hospital settings can exacerbate gaps and burdens in healthcare systems. In hospitals, social workers often take on the majority of responsibility for facilitating patient discharge transitions out of hospital care. Research in this area to date has explored experiences and outcomes of homeless clients, and the experiences of social workers in these roles are not well known. The current study's objective was to elucidate observations and experiences of hospital social workers who discharge patients into homelessness. A total of 112 social workers responded to an online questionnaire, and responses to open-ended questions were analyzed for thematic content. Four overarching themes emerged: (1) complexity of clients, (2) systemic barriers, (3) resource gaps, and (4) negative impact on social workers. It is clear that significant change is required to address the multitude of challenges that intersect to reinforce health inequities. Results can be used by social workers, health authorities, community providers, researchers, and policymakers in discussions about best practices for homeless clients.

A Network Analysis of Selected Psychosocial Factors in Vulvodynia and Its Subtypes.

OBJECTIVE: Psychosocial factors are related to pain and sex-related outcomes in provoked vulvodynia and possibly in mixed and spontaneous vulvodynia. However, a broader behavioral framework, such as the psychological flexibility model, has received limited attention in this context. Recently, additional psychosocial variables have also emerged that appear relevant to vulvodynia, including perceived injustice, body-exposure anxiety during intercourse, and unmitigated sexual communion. The present study applied network analysis to explore relations between psychological flexibility, newly emerging psychosocial variables relevant to vulvodynia, and their associations with vulvodynia outcomes. The study also explored potential differences across vulvodynia subtypes. DESIGN: An online cross-sectional study of 349 participants with vulvodynia (112 provoked, 237 spontaneous/mixed) was carried out. METHODS: Participants completed self-report questionnaires, including questions on pain and sexual outcomes, depression, facets of psychological flexibility, body-exposure anxiety during intercourse, unmitigated sexual communion, and perceived injustice. Networks were computed for the total sample and for provoked and mixed/spontaneous vulvodynia subsamples. RESULTS: Perceived injustice, pain acceptance, and depression were "central" factors among the included variables, in all models. Psychological flexibility processes were relevant for all networks. Depression was more central in the network for mixed/spontaneous vulvodynia; body-exposure anxiety during intercourse was most central for the provoked subtype. CONCLUSIONS: Among the included variables, perceived injustice, pain acceptance, depression, and psychological flexibility appear to be important in vulvodynia. As different factors are significant across subtypes, tailored treatment approaches are suggested.

Implementing Lifestyle Medicine Education in a New Public Health and General Preventive Medicine Residency Program.

Mississippi ranks as the nation's least-healthy state. There is a shortage of trained preventive medicine (PM) physicians in the state. The Department of Preventive Medicine at The University of Mississippi Medical Center was reinstated in 2015 to address this need. Initial PM residency accreditation was awarded in November of 2017 with subsequent notification of 10-year accreditation status in April of 2020 allowing up to 4 PGY-2 and 4 PGY-3 resident positions per year. The residency experiences provided by the program are varied and unique due to the program being housed in both the School of Medicine and the School of Population Health. Preventive medicine residents have the opportunity to complete the American College of Lifestyle Medicine's Lifestyle Medicine Residency Curriculum. Through our diverse didactic and clinical experiences, we are optimistic that our program will continue to attract, train, and retain PM physicians for our state.

Not a fungi to be with: Shiitake mushroom flagellate dermatitis.

Shiitake dermatitis is a rare adverse cutaneous reaction to the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). We report the case of a patient who developed a striking linear flagellate dermatitis without urticaria three days after returning from a trip from Tokyo where he had eaten shiitake mushrooms. The rash resolved after two weeks with topical corticosteroids and antihistamines given for symptomatic relief. Shiitake dermatitis is thought to be either a toxic or hypersensitivity reaction to lentinan, a heat-inactivated polysaccharide found in the cell walls of shiitake mushrooms. Although this mushroom is widely consumed in Eastern Asia, with the increasing globalisation of cuisine and travel, cases are likely to become more common in the Western world.

Non-invasive strategies for stimulating endogenous repair and regenerative mechanisms in the damaged heart.

The adult myocardium, including human, harbours a population of resident multi-potent cardiac stem cells (CSCs), which when stimulated under the right conditions can give rise to new cardiomyocytes and vasculature. Elucidation of the cellular and molecular mechanisms that govern CSC biology and their role in myocardial regeneration will allow the design and development of optimal therapeutic interventions. It is now evident that different growth factors and cytokines govern CSC survival, proliferation, migration and differentiation, as well as playing a role in activating cardiac repair mechanisms such as improving angiogenesis, cardiomyocyte survival and limiting fibrosis. This review article will summarize the evidence for a role of VEGF, NRG-1, IGF-1, HGF, EGF, FGF and TGF-ß1 in modulating the repair and regeneration of cardiac tissue. It will also discuss the use of exosomes and exercise training as interventions to stimulate the endogenous repair and regenerative mechanisms in the damaged heart.

"Trying to Get a Grip": Language Competence and Self-Reported Satisfaction With Social Relationships Three Decades Post-Childhood Traumatic Brain Injury.

OBJECTIVE: (1) To investigate outcomes in language competence and self-reported satisfaction with social relationships in long-term survivors of childhood traumatic brain injury (TBI); and (2) to establish whether language competence contributes to self-reported satisfaction with social relationships decades after sustaining childhood TBI. PARTICIPANTS: Twelve females and 8 males aged 30 to 55 (mean = 39.80, standard deviation = 7.54) years who sustained a TBI during childhood and were on average 31 years postinjury (standard deviation = 9.69). An additional 20 participants matched for age, sex, handedness, years of education, and socioeconomic status constituted a control group. MAIN MEASURES: Test of Language Competence-Expanded Edition and the Quality of Life in Brain Injury questionnaire. RESULTS: Individuals with a history of childhood TBI performed significantly poorer than their non-injured peers on 2 (Ambiguous Sentences and Oral Expression: Recreating Sentences) out of the 4 Test of Language Competence-Expanded Edition subtests used and on the Quality of Life in Brain Injury subscale assessing satisfaction with social relationships. In the TBI group, scores obtained on the Ambiguous Sentences subtest were found to be a significant predictor of satisfaction with social relationships, explaining 25% of the variance observed. CONCLUSIONS: The implication of high-level language skills to self-reported satisfaction with social relationships many decades post-childhood TBI suggests that ongoing monitoring of emerging language skills and support throughout the school years and into adulthood may be warranted if adult survivors of childhood TBI are to experience satisfying social relationships.

Interaction between a CSK gene variant and fish oil intake influences blood pressure in healthy adults.

Blood pressure is a heritable determinant of cardiovascular disease (CVD) risk. Recent genome-wide association studies have identified several single-nucleotide polymorphisms (SNPs) associated with blood pressure, including rs1378942 in the c-Src tyrosine kinase (CSK) gene. Fish oil supplementation provides inconsistent protection from CVD, which may reflect genetic variation. We investigated the effect of rs1378942 genotype interaction with fish oil dosage on blood pressure measurements in the MARINA (Modulation of Atherosclerosis Risk by Increasing doses of N-3 fatty Acids) study, a parallel, double-blind, controlled trial in 367 participants randomly assigned to receive treatment with 0.45, 0.9, and 1.8 g/d eicosapentaenoic acid [EPA (20:5n-3)] and docosahexaenoic acid [DHA (22:6n-3)] (1.51:1) or an olive oil placebo for 12 mo. A total of 310 participants were genotyped. There were no significant associations with blood pressure measures at baseline; however, the interaction between genotype and treatment was a significant determinant of systolic blood pressure (SBP) (P = 0.010), diastolic blood pressure (DBP) (P = 0.037), and mean arterial blood pressure (MABP) (P = 0.014). After the 1.8 g/d dose, noncarriers of the rs1378942 variant allele showed significantly lower SBP (P = 0.010), DBP (P = 0.016), and MABP (P = 0.032) at follow-up, adjusted for baseline values, than did carriers. We found no evidence of SNP genotype association with endothelial function (brachial artery diameter and flow-mediated dilatation), arterial stiffness (carotid-femoral pulse wave velocity and digital volume pulse), and resting heart rate. A high intake of EPA and DHA could help protect noncarriers but not carriers of the risk allele. Dietary recommendations to reduce blood pressure in the general population may not necessarily benefit those most at risk. This trial was registered at controlled-trials.com as ISRCTN66664610.

Primary and secondary intralymphatic histiocytosis.

BACKGROUND: Intralymphatic histiocytosis (IH) is a rare condition often associated with systemic disease. A benign condition, clinical presentations can vary greatly and its cause is largely unknown. Histologically, there are macrophages within distended lymphatic vessels, although this can be an incidental finding or the primary abnormality. OBJECTIVE: We present a series of 7 cases of IH with and without disease associations, and a review of the literature. We propose IH as either primary (without associated conditions) or secondary (associated with systemic disease). METHODS: This was a retrospective collection of patients whose skin biopsy specimens revealed intralymphatic collections of histiocytes. We reviewed their clinical presentation, disease associations, and staining of slides with CD68 in all cases, D2-40 in 5 cases, and HLA-DR in 4 cases. RESULTS: Clinical features were highly variable, and not all cases were associated with systemic disease. One case had admixed reactive angioendotheliomatosis. All 4 cases stained for HLA-DR showed strong expression by the intralymphatic macrophages. LIMITATIONS: Retrospective analysis and limited numbers are limitations. CONCLUSION: IH is not always associated with systemic disease although macrophage activation nevertheless implies immune activation.

Unilateral vulval swelling in cyclists: a report of 8 cases.

OBJECTIVE: To define the clinical features, imaging results, histopathologic patterns, and clinical outcomes seen in patients who develop vulval swelling as a result of intensive cycling. METHODS: The case notes of 8 female cyclists were retrospectively reviewed. RESULTS: The mean age of the patients was 45 years, and all were cycling long distances each week (range, 125-450 km; median, 210 km). All patients had a unilateral swelling of the labium majus. Five patients had magnetic resonance imaging showing asymmetry of the vulva with no enhanced signaling associated with inflammation. Histologic examination in 3 cases revealed dermal fibrosis and dermal edema associated with dilatation of lymphatic vessels. In 1 case, a perifollicular inflammatory infiltrate containing epithelioid granulomas was seen but Crohn's disease was excluded. In another case, fibromuscular hyperplasia was seen. Six patients had surgical excision of the swollen area, and 4 patients were able to resume cycling without problems up to 5 years of follow-up. The cosmetic appearance was initially considered satisfactory by 5 patients. However, 2 patients required a second surgical procedure to further improve the cosmetic appearance. In 1 case, there was a postoperative hematoma followed by an immediate recurrence of the swelling, which persisted. CONCLUSIONS: Unilateral swelling of the labium majus occurring in cyclists can be related to dermal fibroedema associated with lymphatic dilatation or to an increase in adipose tissue. Surgical results were satisfactory in 5 of the 6 patients who underwent excision.

Genetic variation at the FADS1-FADS2 gene locus influences delta-5 desaturase activity and LC-PUFA proportions after fish oil supplement.

Delta-5 and delta-6 desaturases (D5D and D6D) are key enzymes in endogenous synthesis of long-chain PUFAs. In this sample of healthy subjects (n = 310), genotypes of single nucleotide polymorphisms (SNPs) rs174537, rs174561, and rs3834458 in the FADS1-FADS2 gene cluster were strongly associated with proportions of LC-PUFAs and desaturase activities estimated in plasma and erythrocytes. Minor allele carriage associated with decreased activities of D5D (FADS1) (5.84 × 10(-19) ≤ P ≤ 4.5 × 10(-18)) and D6D (FADS2) (6.05 × 10(-8) ≤ P ≤ 4.20 × 10(-7)) was accompanied by increased substrate and decreased product proportions (0.05 ≤ P ≤ 2.49 × 10(-16)). The significance of haplotype association with D5D activity (P = 2.19 × 10(-17)) was comparable to that of single SNPs, but haplotype association with D6D activity (P = 3.39 × 10(-28)) was much stronger. In a randomized controlled dietary intervention, increasing eicosapentaenoic acid (EPA, 20:5n-3) and docosahexaenoic acid (DHA, 22:6n-3) intake significantly increased D5D (P = 4.0 × 10(-9)) and decreased D6D activity (P = 9.16 × 10(-6)) after doses of 0.45, 0.9, and 1.8 g/day for six months. Interaction of rs174537 genotype with treatment was a determinant of D5D activity estimated in plasma (P = 0.05). In conclusion, different sites at the FADS1-FADS2 locus appear to influence D5D and D6D activity, and rs174537 genotype interacts with dietary EPA+DHA to modulate D5D.

Adiponectin gene variant interacts with fish oil supplementation to influence serum adiponectin in older individuals.

Marine n3 polyunsaturated fatty acids (PUFAs) activate the transcription factor peroxisome proliferator-activated receptor (PPARγ), which modulates the expression of adiponectin. We investigated the interaction of dietary n3 PUFAs with adiponectin gene (ADIPOQ) single nucleotide polymorphism (SNP) genotypes as a determinant of serum adiponectin concentration. The Modulation of Atherosclerosis Risk by Increasing Doses of n3 Fatty Acids study is a parallel design, double-blind, controlled trial. Serum adiponectin was measured in 142 healthy men and 225 women aged 45-70 y randomized to treatment with doses of 0.45, 0.9, and 1.8 g/d 20:5n3 and 22:6n3 (1.51:1), or placebo for 12 mo. The 310 participants who completed the study were genotyped for 5 SNPs at the ADIPOQ locus: -11391 G/A (rs17300539), -11377 C/G (rs266729), -10066 G/A (rs182052), +45 T/G (rs2241766), and +276 G/T (rs1501299). The -11391 A-allele was associated with a higher serum adiponectin concentration at baseline (n = 290; P < 0.001). The interaction between treatment and age as a determinant of adiponectin was significant in participants aged >58 y after the highest dose (n = 92; P = 0.020). The interaction between +45 T/G and treatment and age was a nominally significant determinant of serum adiponectin after adjustment for BMI, gender, and ethnicity (P = 0.029). Individuals homozygous for the +45 T-allele aged >58 y had a 22% increase in serum adiponectin concentration compared with baseline after the highest dose (P-treatment effect = 0.008). If substantiated in a larger sample, a diet high in n3 PUFAs may be recommended for older individuals, especially those of the +45 TT genotype who have reported increased risk of hypoadiponectinemia, type 2 diabetes, and obesity.

The spectrum of histopathologic patterns secondary to the topical application of EMLA® on vulvar epithelium: clinicopathological correlation in three cases.

EMLA(®) (eutectic mixture of local anesthetics, 2.5% each of lidocaine and prilocaine in an oil and water emulsion) is used as a topical anesthetic. We report three cases of EMLA(®) -induced histopathologic changes on the vulvar epithelium. While there are some similar histopathologic features to those reported in extragenital skin, we describe additional findings on vulvar epithelium, which, to our knowledge, have not been reported previously. The patients presented with clinical signs suggestive of lichen sclerosus or erosive lichen planus (LP), but were all confirmed histopathologically as LP. The biopsy was taken after 15 min of EMLA(®) application and intradermal injection of 1% lidocaine. Blistering prior to intradermal lidocaine and the biopsy procedure was observed in two patients. The histopathologic changes observed in the epithelium included pallor of the upper epidermis, mild spongiosis, intraepidermal subcorneal and suprabasal acantholysis, congestion of the papillary dermal capillaries and extravasated erythrocytes. Basophilic granules were present, but rare, while the necrosis with multifocal clefting was more marked than in extragenital skin. It is important to be aware of these changes occurring on genital mucosa; these may occur in the absence of clinical signs and may obscure the primary underlying pathology, thus representing a diagnostic pitfall.

Gliflozin (SGLT2 inhibitor) induced vulvitis.

INTRODUCTION: Sodium-glucose co-transporter 2 (SGLT2) inhibitors, or gliflozins, are used as mono or combined therapy in the management of diabetes. Genital infections are the most common reported adverse effect, as a result of induced glycosuria. Cutaneous features of patients experiencing vulval symptoms while on SGLT2 inhibitor therapy have not been clearly described in published literature. We have observed a specific inflammatory vulvitis with psoriasiform features in patients taking SGLT2 inhibitors, related to candidiasis in most cases. METHODS AND RESULTS: Demographic and treatment outcomes of 11 patients with characteristic inflammatory changes after starting SGLT2 inhibitors were extracted from electronic records. Ninety-one percent (n = 10) had candidiasis, treated with fluconazole. Six (54.5%) were able to continue SGLT-2 inhibitors through the addition of topical treatments, but five patients had to discontinue the drug. CONCLUSIONS: SGLT2 inhibitors can result in characteristic inflammatory vulvitis. Treatment with topical agents and single-dose antifungals may allow patients to continue their therapy to achieve improved glycemic control. In resistant cases, discontinuation of the drug is necessary. We highlight this effect so that early treatment can be initiated to alleviate symptoms and recognition of underlying cause.