Vulvar intraepithelial neoplasia: Classification, epidemiology, diagnosis, and management.

Vulvar intraepithelial neoplasia (VIN) is classified into two entities: differentiated (dVIN) and vulvar high-grade squamous intraepithelial lesions (vH-SIL). dVIN is a premalignant lesion that develops on an existing vulvar lesion such as lichen sclerosus, while vH-SIL is associated with HPV infection. The two entities differ in terms of pathophysiology, background, prognosis, and management. The incidence of VIN in young women is rising and recurrence is common, even after radical surgery, which can cause significant disfigurement. Alternative strategies include topical treatments, ablation, and a watch-and-wait approach. There is currently no consensus on how these lesions should be managed. We review the literature in this field.

Prospective Assessment of First-Year Quality of Life After Pelvic Exenteration for Gynecologic Malignancy: A French Multicentric Study.

BACKGROUND: Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent. METHODS: A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure. RESULTS: The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration. CONCLUSIONS: Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery.

Laparoscopic hysterectomy after concurrent radiochemotherapy in locally advanced cervical cancer compared to laparotomy: A multi institutional prospective pilot study of cost, surgical outcome and quality of life.

OBJECTIVE: Laparoscopy allows hysterectomies after chemoradiation to be performed without opening the abdominal wall. We measured the costs and quality of life for locally advanced cervical cancer patients operated on via laparoscopy compared to laparotomy. STUDY DESIGN: We conducted an observational prospective multicenter study on locally advanced cervical cancer patients undergoing an extrafascial hysterectomy after concurrent chemoradiotherapy (CRT). We assessed the costs from the medical visit before surgery up to the first month after surgery from the providers' perspective and measured the quality of life using the EORTC QLQ-C30 and QLQ-CX24 up to six months. RESULTS: Sixty two patients (39 laparoscopy and 23 laparotomy) from December 2008 to November 2011 were included. There was no difference in operative time, or intraoperative and post-operative complication rates between the two groups. Intraoperative transfusion and abdominal drain were significantly lower in the laparoscopy group (respectively, p = 0.04 and p < 0.01), as well as the duration of hospital stay (7.3 d vs. 5.7 d, p < 0.001). All patients who underwent laparoscopic hysterectomy were discharged to home, whereas 4 laparotomy patients used convalescence homes (p = 0.01). Mean costs at one month were €10,991 for laparotomy and €11,267 for laparoscopy (p = 0.76). Sexual activity is better for the laparoscopy group at six months (p = 0.01). CONCLUSION: Laparoscopy for an extrafascial hysterectomy after CRT in locally advanced cervical cancer patients brought better quality of life with similar costs compared to laparotomy, and should therefore be the first choice for surgeons.

[((18)F)-fluorodeoxyglucose PET/CT in cervix cancer: lymph node assessment and prognostic/predictive value of primary tumour analysis]. / Tomographie par émission de positons au ((18)F)-fluorodésoxyglucose dans les cancers du col utérin : évaluation ganglionnaire et valeur pronostique/prédictive des données de la tumeur primitive.

PURPOSE: In cervix carcinoma: (a) to evaluate the ability of ((18)F)-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the lymph node detection; (b) to investigate the prognostic and predictive value of the primary cervical PET parameters. PATIENTS AND METHODS: Ninety patients treated for cervix carcinoma and evaluated initially by MRI and FGD PET were included. The performances of FDG-PET for lymph node detection (relatively to the lymph node dissection) have been described (sensitivity, specificity, positive predictive value and negative predictive value). PET tumour parameters analyzed were: maximum standard uptake value (SUVmax), the volume and the maximum diameter. The prognostic and predictive values of these parameters were investigated. The tumour response was evaluated on surgical specimens. RESULTS: PET detected the cervical tumour with a sensitivity of 97% (mean values: SUVmax=15.8, volume=27 mm(3), maximum diameter=47). For the detection of the lymph nodes, the values of sensibility, specificity, positive predictive value and negative predictive value were: 86, 56, 69 and 78% in the pelvic, and 90, 67, 50 and 95% for the para-aortic area, respectively. The SUVmax was correlated with histologic response (P=0.04). The frequency of partial histological response was significantly higher for tumour SUVmax>10.9 (P=0.017). The maximum PET diameter and pathologic response had an impact on disease-free survival and overall survival in multivariate analysis (P<0.05). CONCLUSION: PET has high sensitivity in detecting pelvic and para-aortic lymph nodes. Some primary cervical tumour PET parameters are useful as prognostic and predictive factors.

[Cervical screening: toward a new paradigm?]. / Un nouveau paradigme pour le dépistage du cancer du col utérin?

OBJECTIVES: Analysis of the trials which compare the virologic testing (HPV testing) and the cytology in the cervical screening. MATERIAL AND METHODS: The MedLine database was consulted using the Keywords: "cervical screening", "pap smear", "liquid based cytology", "HPV testing", "adults", "adolescents", "cervical intraepithelial neoplasia (CIN)", "uterine cervix cancer". Articles were selected according their concern about the debate of the uterine cervix cancer screening in France. RESULTS: The HPV testing seems interesting allowing a decreasing delay in the diagnosis of CIN (more diagnosis of CIN2+ in the first round and less during the second one). But, when the two rounds are added, the number of CIN2+ are identical in the two arms (cytology and HPV testing) in all the trials (except the Italian NTCC trial). A negative HPV testing protects the women much longer than cytology can do: a delay of five years between two rounds seems ideal. The HPV testing alone increases the detection rate of cervical lesions, which could regress spontaneously and may induce an overtreatment, especially in the youngest population: a triage is necessary and the cytology appears to be the best way to select the candidates for colposcopy in case of positive HPV testing and cytology. The HPV infection presents some particularities in adolescent females: for this reason, the HPV testing should not be used in this special population. In vaccinated women, a consensus for the screening is necessary. CONCLUSION: The health care providers in France have to understand the characteristics of the HPV testing: its advantages compared to the cytologic screening are only evident in case of an organization of the screening in France and even in Europe.

Quantitative assessment of skin aging.

Noninvasive methods have allowed physicians to give an objective description of aged skin in terms of functional and esthetic properties. The relative influence of environment (mainly sun) on the true aging process can be assessed through the obtained data. It is also possible to measure the efficacy of topical preparations (cosmetics or drugs) designed for treating the various cutaneous aging marks.

Utility of three-dimensional computed tomographic angiography for assessment of relationships between the vertebrobasilar system and the cranial base.

OBJECTIVE: The optimal surgical exposure for basilar tip aneurysms is dictated by the relationship of the basilar bifurcation to the cranial base. This study was designed to evaluate three-dimensional computed tomographic angiography as a means of obtaining detailed anatomic information on the basilar artery and the surrounding cranial base in individual patients before surgery. METHODS: We studied 30 patients using three-dimensional computed tomographic angiographic reconstructions from 1-mm computed tomographic slices. Detailed anatomic measurements were performed to define the relationship between the basilar artery and the cranial base. Particular attention was paid to the height of the dorsum sellae and its relationship to the basilar bifurcation. RESULTS: The heights of the basilar apex and the vertebrobasilar junction, relative to the cranial base, were extremely variable. Considerable asymmetries in the heights of the left and right posterior clinoid processes were identified; in one case, this difference was more than 1 cm (mean difference in height, 0.9 mm; range, 0-10.3 mm). The heights of the posterior clinoid processes above the sellar floor ranged from 5.8 to 14.1 mm (mean height, 9.5 mm). We were able to determine the feasibility of the pterional/orbitozygomatic, middle fossa/ anterior petrosal, and presigmoid retrolabyrinthine approaches to an individual basilar bifurcation. We also estimated the amount of bone removal required and determined the operative distances via those approaches. CONCLUSION: Three-dimensional computed tomographic angiography is a useful tool for assessing critical anatomic relationships and represents an adjunct to conventional angiography in the planning of individualized, precisely tailored, cranial base approaches to the vertebrobasilar system.

EEMCO guidance for the assessment of skin topography. The European Expert Group on Efficacy Measurement of Cosmetics and other Topical Products.

Numerous factors can modify the visibility or the actual dimensions of the skin microrelief and wrinkles. To quantify these changes, several methods, including clinical and non-invasive ones, have been proposed. This article reviews the advantages et drawbacks of all of them and lists some experimental recommendations to make the results of studies using these methods, more reliable.

[Analysis of medical catalog terms using the MAOUSSC model: application to Gyncecology-Obstetrics]. / Analyse des libellés des actes du catalogue des actes médicaux à l'aide du modèle MAOUSSC: application à la Gynècologie-Obstétrique.

BACKGROUND: The Model of Assistance and Orientation of a User within a System of Coding (MAOUSSC) used to describe activity in human medicine was used to analyse French medical nomenclature in Gynecology and Obstetrics. METHODS: French medical nomenclature for gynecology and obstetrics was translated with the multiaxial model (MAOUSSC) to allow critical analysis. RESULTS: All the 119 medical acts in the French nomenclature involving the female genital tract and obstetrics could be translated with the model. 24% of the acts were imprecise, ambiguous or implicit: the nature of the procedure was not explicit in 7 cases, the surgical route was not given in 86 and the surgical instrumentation not named in 75. Activities involving numerous medical specialties and ambulatory activity can be described with the MOUSSC model. CONCLUSION: The MAOUSSC model is still in the experimental stage. It is however easy to implement, has a high potential for describing various medical acts and is suitable for the description of gynecological and obstetrical activity both in terms of economical and medical efficacy.

Preoperative color-Doppler assessment of vascularisation of the rectus abdominis: anatomic basis of breast reconstruction with a transverse rectus abdominis myocutaneous flap--a prospective study.

The unipedicled TRAM flap is an useful alternative to breast reconstruction after mastectomy in patients who refuse mammary implants. There is however the risk of unpredictable partial skin necrosis even after rigorous surgical procedures. Certain authors have proposed color flow doppler assessment before reconstructive surgery better to identify the vascular network and optimise patient selection. We performed a prospective study in 20 outpatients in order to compare preoperative assessment of the blood supply to the abdominal flap with the operative findings. An Ultramark 9 HDI (Advanced Technology Laboratories) equipped with a high frequency (10 Mhz) linear probe was used to measure blood flow and vessel caliber in the epigastric a. and perforating vessels (localisation, number; peak flow). Despite three limiting factors (anatomic, technical, morphologic) the results obtained in this series could be used to determine the indications for a TRAM flap.

CPOM: alleviating the demand for ICU beds.

Technology is adapting to health care's changing environment as more acutely ill patients, including those with respiratory risks, are being placed on the general care units. Centralized noninvasive pulse oximetry, a method to measure oxygen saturation, provides a relatively inexpensive, efficient means to serve a broader spectrum of patients.

Echographic assessment of corticosteroid-induced skin-thinning, including echogenicity measurement.

BACKGROUND/AIMS: Skin atrophy is one of the main side effects of long-term topical corticosteroid therapy. It has already been studied through ultrasound skin-thickness measurement. In this study, the quantification of dermal echogenicity was introduced to provide new information on this phenomenon. METHODS: Skin thinning induced by topical application (without occlusion) of the superpotent corticosteroid clobetasol propionate (0.05% lotion), was assessed by means of ultrasonography in terms of thickness and echogenicity. 15 healthy volunteers were treated for 6 weeks, 1 daily, 5 days a week on the forearms. RESULTS: The thinning showed a biphasic pattern, with a 1st period of rapid change (about 15% of thinning in a week) followed by a period of slower but significant change. Skin thickness returned to baseline values 3 weeks after the end of treatment. Dermal echogenicity, which represents the mean intensity of the ultrasound signals reflected by the dermis, was found to follow the same variations, increasing strongly during the 1st week, then more slowly. The 2 parameters are correlated and probably reflect the same physiological modifications responsible for skin thinning, i.e., a reduction in glycosaminoglycan synthesis (leading to a drastic fall in dermal water content) and vasoconstriction. CONCLUSION: This sensitive and non invasive method enables us to identify the effects of clobetasol propionate on the healthy dermis in the absence of any clinical signs of thinning.

The economic value of contraception: a comparison of 15 methods.

OBJECTIVES: The purpose of the study was to determine the clinical and economic impact of alternative contraceptive methods. METHODS: Direct medical costs (method use, side effects, and unintended pregnancies) associated with 15 contraceptive methods were modeled from the perspectives of a private payer and a publicly funded program. Cost data were drawn from a national claims database and MediCal. The main outcome measures included 1-year and 5-year costs and number of pregnancies avoided compared with use of no contraceptive method. RESULTS: All 15 contraceptives were more effective and less costly than no method. Over 5 years, the copper-T IUD, vasectomy, the contraceptive implant, and the injectable contraceptive were the most cost-effective, saving $14,122, $13,899, $13,813, and $13,373, respectively, and preventing approximately the same number of pregnancies (4.2) per person. Because of their high failure rates, barrier methods, spermicides, withdrawal, and periodic abstinence were costly but still saved from $8933 to $12,239 over 5 years. Oral contraceptives fell between these groups, costing $1784 over 5 years, saving $12,879, and preventing 4.1 pregnancies. CONCLUSIONS: Contraceptives save health care resources by preventing unintended pregnancies. Up-front acquisition costs are inaccurate predictors of the total economic costs of competing contraceptive methods.

[Pregnancy in the diabetic woman. Incidence of malformations, of macrosomia, update on obstetrical management]. / La grossesse de la femme diabétique. Incidence des malformations, de la macrosomie, mise à jour sur la conduite obstétricale.

Perinatal mortality for infants born to diabetic mothers has dropped in the years from the 1950's when it was 20% to less than 3% by the end of the 1980's. In spite of this considerable reduction which is due to careful observation and multidisciplinary management in this type of pregnancy, the congenital malformation rate is 4 times greater than with the general population (3%) and the rate of spontaneous abortions is double (13%). The caesarean section rate is 5 times higher (18%). In bringing out a retrospective study we have attempted to analyse the endocrinological and obstetrical features of the cases.

[Radical prostatectomy and biologic glue]. / Prostatectomie radicale et colle biologique.

Fibrin glue (reconstituted fibrin glue-Tissu-col-Immuno-France) was used in 24 patients following radical prostatectomy with ilio-obturator lymphadenectomy (Group II) to improve haemostasis of the operative field, to decrease or eliminate lymphatic oozing and to promote healing of the urethrovesical anastomosis. The results in terms of duration of drainage, quantity of fluid evacuated by these drains, operative complications and length of hospital stay were compared to those obtained in 24 clinically identical patients operated previously without the use of fibrin glue (Group I). Although fibrin glue is easy to use, ensures a particularly dry operative field at the end of the operation and does not induce any infectious complications (abscess, hepatitis), it increases the cost of the operation (5 ml vial = 2,500 FF) and the use of this product does not reduce the drainage time (Group I: 7 +/- 4.6 days; Group II: 8.5 +/- 5.4 days) the volume of blood or lymphatic discharge (Group I: 500 +/- 570 ml; Group II: 660 +/- 825 ml) or the length of hospital stay (Group I: 16.5 +/- 4.8 days; Group II: 17.4 +/- 5.5 days). These results argue against the routine use of fibrin glue in radical prostatectomy.

Assessment of aging of the human skin by in vivo ultrasonic imaging.

The ultrasonic imaging technique that we have developed provides cross-sectional images of human skin in vivo with a resolution of about 80 microns axially (i.e., deep into the skin) and 250 microns lateral (parallel to the surface). In order to study aging skin, we obtained ultrasonic images from the mid-forearm (volar and dorsal sides) of 142 women. Ultrasonically, on the images, the dermis appears composed of two bands: a dark superficial one where the ultrasonic waves are propagated in a relatively homogeneous or non-echogenic medium, and a deeper one, which is lighter in color, suggesting a heterogeneous medium. Our results show that skin is thicker on the dorsal than on the volar forearm. In contrast to previously published results, skin thickness remains constant until the seventh decade of life, diminishing thereafter. The relative thickness of the two bands show marked variations with age: a progressive thickening of the dark band, from zero in infants to approximately 75% of total skin thickness in aged subjects, while the light band shows the inverse trend. Comparing the amplitude of the bands on the volar and dorsal forearm, the relative thickness of the dark band is larger on the dorsal (exposed) side and increases with age. These findings and the analysis of variously stained biopsies taken in some of our patients lead us to assign this dark band to a zone in the upper dermis where the collagen network is delicate, dense, and well organized. This is supported by some data in the literature. The thickness of this subepidermal non-echo-genic band appears to be a far more sensitive marker of skin aging at the dermal level than is the measurement of skin thickness.

Assessment of topical non-steroidal anti-inflammatory drugs.

A new non-invasive technique for assessing the efficacy of topical non-steroidal anti-inflammatory drugs (NSAID) in man is proposed. The NSAID are initially applied to the skin under occlusion before inflammation is induced by a methyl nicotinate solution. The inflammatory response is quantified in terms of cutaneous blood flow by a laser Doppler velocimeter (LDV). The efficacy of NSAID preparations is calculated by comparing the responses of the LDV to the methyl nicotinate challenge on the pretreated and the non-treated skin sites. This protocol has been used to investigate the effect of three different NSAID preparations (indomethacin, niflumic acid, palmitoyl collagenic acid) and the influence of the vehicle on the efficacy of indomethacin. The three preparations tested gave positive results but with different amplitudes in response. The efficacy of indomethacin varied with the vehicle used.

An in vivo assessment of the biomechanical properties of human skin modifications under the influence of cosmetic products.

Synopsis A new device using a torsional technique has been developed to record the biomechanical properties of the skin. After determination of the optimal experimental conditions, effects of cosmetic products on the stratum corneum biomechanical properties are described.