Basal cell carcinoma of the vulva: treatment with Mohs micrographic surgery.

Vulval basal cell carcinomas (BCCs) are rare, representing < 5% of vulval malignancies and 1% of all BCCs. They often present with nonspecific symptoms and features that lead to large, poorly circumscribed and late-presenting lesions. Current and conventional treatments used to treat vulval BCC include cryotherapy, imiquimod and excision. However, recurrence rates as high as 20% have been reported with these treatments. Furthermore, there are no current clinical guidelines for their management. We present the first reported series of patients with vulval BCC treated with Mohs micrographic surgery (MMS). We report seven cases of vulval BCC treated with MMS at a tertiary referral centre over 3 years. Follow-up was performed at 3 months and up to 3 years. Our series demonstrates that there were no postoperative complications, functional sequelae or recurrences up to the 3-year follow-up. We therefore recommend that MMS should be considered in the management of vulval BCCs.

The treatment of vulval lichen sclerosus in prepubertal girls: a critically appraised topic.

Lichen sclerosus is one of the dermatoses that specifically affects the anogenital skin. It has peaks of incidence in prepubertal girls and postmenopausal women. The objective of this critical appraisal was to review systematically the evidence for efficacy and safety of different treatments. There are no randomized controlled studies of treatment in prepubertal girls and most studies are small case series or case reports. There is little focus on quality of life.

2016 European guideline for the management of vulval conditions.

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

Randomized telephone smoking-intervention trial initially directed at blue-collar workers.

Although smoking prevalence in the United States has declined markedly in recent years, prevalence among blue-collar workers remains high and few successful methods of reaching this group have been identified. The present study was designed to test the relative efficacy of two different approaches to telephone smoking-cessation counseling for blue-collar workers. Our study built on the experience of the National Cancer Institute's Cancer Information Service (CIS) and compared the past CIS smoking-cessation counseling procedure and a modified version of the present procedure. In our trial, callers to a special telephone hotline who asked for information on smoking cessation were randomly assigned to receive counseling under one of two protocols: 1) the past CIS procedure, in which general information was given and cessation materials were sent to the callers, and 2) a version of the present CIS stage-model procedure, adapted by us for use with blue-collar workers, in which callers were given counseling specific to their stage in the smoking-cessation process. The general-information group contained 185 subjects; the stage-model group contained 197. Despite extensive efforts in the present study, it was not possible to recruit the number of blue-collar workers planned for our statistical analysis. Consequently, of a total of 382 subjects recruited, 93 (24.3%) were blue-collar workers, 181 (47.4%) were white-collar workers, and 108 (28.3%) were retired persons who worked part time, student workers, or the unemployed. Our results show no statistically significant differences in either short-term or long-term nonsmoking rates between the general-information group and the stage-model group.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct observations of surgical wound infections at a comprehensive cancer center.

OBJECTIVES: To identify the rate of surgical site infection and risk factors for surgical site infection in patients with cancer and to evaluate antibiotic use patterns on surgical oncology services. DESIGN: Criterion standard. SETTING: Memorial Sloan-Kettering Cancer Center, a comprehensive cancer center at a university hospital. PATIENTS: Over a 15-month period, 1226 patients undergoing 1283 surgical procedures performed by the Breast, Colorectal, and Gastric-Mixed Tumor surgical services. MAIN OUTCOME MEASURE: Direct observation of surgical sites was performed by a single, surgeon-trained member of the hospital's Infection Control Section, adhering to an established protocol for grading of the surgical site. RESULTS: Operative procedures accounted for the following traditional wound class distributions: class I (clean), 630 cases; class II (clean-contaminated), 577 cases; class III (contaminated), 29 cases; and class IV (dirty-infected), 47 cases. Surgical site infection rates were 3.8% in class I; 8.8% in class II; 20.7% in class III; and 46.9% in class IV procedures. The mean (+/- SD) age was 57.7 +/- 14.3 years and the Anesthesiology Society of America physical assessment score, 2.3 +/- 0.7. The mean (+/- SD) operation time was 145 +/- 104.9 minutes. Logistic regression analysis demonstrated several risk factors for surgical site infection: obesity (P < .0001); a contaminated or dirty-infected surgical procedure category (P < .0001); operation time greater than 4 hours (P = .0004); Anesthesiology Society of America physical assessment score of 3 or greater (P < .01); and preoperative length of stay of 3 or more days (P = .03). CONCLUSIONS: Risk factors for surgical site infection in patients with cancer are similar to those found in the National Nosocomial Infections Surveillance System. However, as an individual risk factor among our patient population, obesity contributed as strongly as the surgical procedure category to a patient's likelihood of acquiring a surgical site infection. In addition to Anesthesiology Society of America status, length of the surgical procedure, and surgical procedure category, obesity should warrant consideration as an individual risk factor for surgical site infection.

Nickel as an occupational allergen. A survey of 368 nickel-sensitive subjects.

OBJECTIVE: To define the role of nickel as an occupational allergen. DESIGN: Survey using path-test results. SETTING: Contact dermatitis clinic in the university hospital of a large industrial British city. PATIENTS: Three hundred sixty-eight nickel-allergic patients seen during a 5-year period were assessed for the relevance of nickel contact in their workplace. Patients were divided into possible occupational nickel allergy and nonoccupational nickel allergy groups. RESULTS: Nickel was considered an occupational allergen or possible occupational allergen in 84 (22.8%) of 368 patients shown to be nickel sensitive on patch testing. The main workers in whom nickel was a common allergen were hairdressers, retail clerks, caterers, domestic cleaners, and metalworkers. Those for whom occupational exposure was possible had a significantly higher prevalence of hand dermatitis compared with the nonoccupational nickel allergy group. Nickel allergy seemed to function as a secondary occupational influence, often in conjunction with other factors, such as irritants. CONCLUSIONS: Although the overall importance of nickel as an occupational allergen cannot be easily assessed, there is evidence of its importance in some occupations, especially those involving wet work. The possibility that nickel is acting as an occupational allergen needs to be assessed on an individual basis, taking into account personal circumstances and environment, but particularly should be considered in patients with hand dermatitis.

The family's functioning with chronic illness in the mother: the spouse's perspective.

While previous research has studied the impact of chronic illness on the patient or spouse, the impact on the marriage, the child, the parent-child relationship, and the family's functioning have been relatively ignored. To date ther is no known study of the impact of a mother's chronic illness on the family. The purpose of the current exploratory study was to test a set of interrelated hypotheses about family functioning with the mother's chronic illness from the spouse's perspective based on a family systems perspective. Data were obtained from standardized questionnaires from 48 fathers with young school-age children whose wife had either breast cancer, diabetes, or fibrocystic breast disease. Results of a path analysis revealed that the number of illness demands the father experienced was a significant predictor of his level of depression. More demands resulted in higher depression scores. Marital adjustment was significantly affected by both the father's level of depression as well as by his wife's type of disease. Spouses of women with breast cancer had significantly higher levels of marital adjustment than did partners of the other women. More depressed spouses had lower levels of marital adjustment. Both illness demands and level of marital adjustment significantly predicted the type of coping behavior the family used. More frequent illness demands and higher levels of marital adjustment were associated with familial introspection, that is, coping behavior characterized by frequent feedback, reflection, and discussion in the family. The quality of the father-child relationship was significantly affected by this type of coping behavior. Families characterized as introspective had fathers who reported more frequent interchange with their children.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV-illness, social support, sense of coherence, and psychosocial well-being in a sample of help-seeking adults.

This study tests a set of hypotheses that predict self-esteem and anxiety in adults infected with human immunodeficiency virus (HIV). The analysis is motivated by the following question: Is the level of perceived coherence, i.e., the extent to which individuals derive meaning and purpose in their lives despite their HIV-illness, related to their levels of self-esteem and anxiety? Data were obtained from one of three HIV care and referral centers in the Midsouth. The results demonstrate that clients who experienced a greater sense of derived meaning and purpose (perceived coherence) from their situations and those with more confidants (social support) reported higher self-esteem and lower anxiety than other HIV-infected adults seeking counseling and maintenance services. Implications are drawn for strategies to meet HIV-related mental health care needs.

The child's adaptation to parental medical illness: theory and clinical implications.

Few resource papers are available to health care providers that address in detail the issues faced by children in adapting to serious parental illness. The current paper offers a developmental approach to understanding the responses and problems of school-age and adolescent children coping with parental medical illness. Four developmental issues are considered: security and separation anxiety, interpersonal understanding, conceptualizations of illness and death and the role of fantasy. Based on these considerations, broad guidelines for clinical interaction are suggested for health professionals working with seriously ill parents and their children.

Living with cancer. Family experiences.

The focus of this paper is to describe what it is like to live with cancer from the perspective of families. Recent studies indicate that family members' concerns vary with their roles as family members and patient/nonpatient status. Moreover, concerns vary with stage of illness and time since diagnosis. Not all concerns are shared among all family members. Families influence the adjustment of the person with cancer. Family members cope in different ways, and coping patterns vary with status of the disease and the person's role in the family. Nevertheless, families coping in different ways can achieve similar outcomes.

The lived experience of self-transcendence in gay men with AIDS.

This phenomenologic study described the structure of self-transcendence in eight gay men with AIDS. The men provided oral or written descriptions of experiences associated with feelings of increased interconnectedness with others, sense of well-being, and meaning and purpose in life. The data were analyzed using Colaizzi's phenomenologic technique. The men experienced self-transcendence in the three ways described by Frankl. Reaching out for help and helping others alleviated the men's sense of aloneness and isolation. Their acceptance of the closeness of death led to a sense of urgency to create a legacy and to participate only in activities that had meaning for them. Knowledge of these views and behaviors may help nurses to create a therapeutic exchange in which self-transcendent views are fostered in other gay men with AIDS.

Balancing our lives: a study of the married couple's experience with breast cancer recurrence.

PURPOSE/OBJECTIVES: To examine the married couple's experience with breast cancer recurrence from each partner's own perspective, to describe their mood and martial quality, and to develop an initial explanatory theory of the couple's lived experience with breast cancer recurrence. DESIGN: Descriptive, qualitative. SETTING: Homes of married couples in the Pacific Northwestern United States. SAMPLES: 15 married couples comprised of women diagnosed with recurrent breast cancer and their husbands. The median length of time since recurrence was 10 months. METHODS: Structured interviews were conducted in the homes of married couples that met eligibility criteria using an open-ended interview schedule, the Marital Dyad Interview, and two standardized questionnaires-the Spanier Dyadic Adjustment Scale and the Center for Epidemiological Studies Depression Scale. MAIN RESEARCH VARIABLES: Lived experience of couples to breast cancer recurrence, depressed mood, and marital adjustment. FINDINGS: BALANCING OUR LIVES was the core category that explained how the couples lived with the breast cancer recurrence. Couples actively worked to balance their lives by keeping the breast cancer a background, not a foreground, issue. Although couples talked about managing the daily realities of the woman's breast cancer, not dwelling on the cancer and moving ahead and healing themselves was most important. Balancing Our Lives involved the couples in four major processes: managing the woman's everyday illness, surviving, healing, and preparing for death. Concurrently, one or both members of 60% of the couples scored outside the normative range on either depressed mood or marital adjustment. CONCLUSIONS: The couples' ways of managing the breast cancer recurrence through balancing their lives may be facilitating their behavioral functioning but may not be enhancing their mood or marital quality. IMPLICATIONS FOR NURSING PRACTICE: The couples' management of recurrence may benefit from additional strategies, including helping them work through sad thoughts or feelings instead of avoiding them; recognizing and supporting each other's views, even when their views differ; and helping them to learn ways to express sad thoughts and feelings without overly dwelling on them.