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).

The impact of the 2011 UK post-exposure prophylaxis for HIV following sexual exposure guidelines: a regional retrospective audit.

A re-audit of prescribing of post-exposure prophylaxis for HIV following sexual exposure in the Thames Valley demonstrated that an updated proforma has led to significant improvements in clinician-led outcomes, but had no impact on completion or follow-up rates.

Hypophosphataemia with non-tenofovir-containing antiretroviral therapy.

Hypophosphataemia with tenofovir (TDF) treatment has been well described. The role of HIV infection and of other antiretroviral (ART) agents in hypophosphataemia has received less attention. The aim of this study was to determine the prevalence of hypophosphataemia in HIV-positive adults. We measured the fasting plasma phosphate level and estimated glomerular filtration rate (eGFR) in 123 HIV-positive patients. A total of 26% had hypophosphataemia and 11% had hypophosphataemia of grades 2-4 (0.65 mmol/L or less). Hypophosphataemia of any grade was more frequent in those who were ART-treated than ART-naive (35% versus 10%; P = 0.0001). Multiple linear regression analysis showed no significant association between phosphate level and gender, TDF status, duration of ART, duration of HIV infection and eGFR. Increasing age was significantly associated with a very small rise in phosphate level. Isolated hypophosphataemia was significantly more frequent in HIV-positive subjects receiving ART than ART-naive individuals, irrespective of the drug regimen.

Field vaccination of sheep with a larval-specific antigen of the gastrointestinal nematode, Haemonchus contortus, confers significant protection against an experimental challenge infection.

The availability of effective vaccines would add a valuable tool to the management of gastrointestinal nematode infections in livestock. While some experimental vaccines have shown protection in laboratory trials, few have been tested in the field. In the present study, eight month old sheep kept on pasture were treated with anthelmintic 8 weeks before vaccination with a larval surface antigen of the nematode parasite, Haemonchus contortus, under a commercially acceptable protocol, i.e. 2 immunizations using a commercial adjuvant; they were then given a controlled challenge infection 4 weeks later in indoor pens. Vaccination of sheep with 4 increasing doses of antigen resulted in significant reductions of 61% and 27% in cumulative faecal egg counts in the two highest dose groups, and a 69% reduction in worm burden in the highest dose group. Blood loss, as determined by packed cell volume, was also significantly reduced in the highest dose group of sheep. One outlier sheep showed an unusual increase in egg count without a concomitant increase in worm burden compared to the control sheep, indicating a vaccine-induced stress response. Antigen-specific serum antibody levels steadily increased in sheep while on pasture and decreased when transported to indoor pens. No difference in antibody levels could be detected between vaccinated and unvaccinated sheep, but all showed increased antibody levels compared to uninfected control sheep kept in indoors pens for 2-3 months, suggesting sheep were sensitized to the larval antigen either from low dose pasture contamination or cross reaction with pasture-related antigens. The results of these studies confirm the protective properties of the larval surface antigen and its protective effect when vaccinations are performed in the field.

European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011.

Three common infections are associated with vaginal discharge: bacterial vaginosis, trichomoniasis and candidiasis, of which trichomoniasis is a sexually transmitted infection (STI). This guideline covers the presentation and clinical findings of these infections and outlines the differential diagnoses. Recommendations for investigation and management based on currently available evidence are made, including the management of persistent and recurrent infections.

The use of prophylaxis against HIV after sexual exposure in pregnancy to reduce the risk of vertical transmission.

We present a case demonstrating the use of HIV prophylaxis post-sexual exposure in pregnancy. This has not been presented before but has certainly been discussed.

Syphilis in pregnancy and the neonatal period.

The recent increase in the number of cases of syphilis in the UK, including among women of reproductive age, has stimulated the need for a review of practices concerning assessment and management of syphilis in pregnancy and the neonatal period. This paper summarizes available evidence from published guidelines, primary and secondary research. Optimal management of syphilis in pregnancy and the neonatal period relies on the early diagnosis and staging of maternal disease, prompt treatment to prevent congenital syphilis, and timely assessment of newborns.

Understanding parental motivators and barriers to uptake of child poison safety strategies: a qualitative study.

OBJECTIVES: To develop an understanding of factors acting as barriers and motivators to parental uptake of child poison safety strategies. DESIGN: A qualitative study involving semistructured interviews and focus groups. A grounded theory approach was used for the collection and analysis of data. PARTICIPANTS: Sixty five parents of children under 5 years of age, some of whom had experienced an unintentional child poisoning incident. RESULTS: A range of knowledge based, environmental, and behavioral barriers to comprehensive parental uptake of poison safety practices were identified. As a result there tended to be only partial implementation of safety initiatives in the home. Selection of safety practices was often guided by the interests and behaviors of the child. This made the child vulnerable to changes in the home environment, inadequate supervision, and/or shifts in their own behavior and developmental ability. Personal or vicarious exposure of a parent to a child poisoning incident was a significant motivator for parental review of safety practices. CONCLUSION: Environmental measures targeting child resistant containers, warning labels, and lockable poisons cupboards will support parents' efforts to maintain poison safety. Additional education campaigns using stories of actual poisoning incidents may help to increase awareness of risk and encourage increased uptake.

Prevention of unintentional injury to people with intellectual disability: a review of the evidence.

BACKGROUND: Recent research evidence shows that people with intellectual disability (ID) have double the unintentional injury risk of the general population and the risk is further increased in the presence of psychopathology and epilepsy. The pattern of injury and the circumstances surrounding an injury event in those with ID have some similarity with that of young children in the general population. Interventions to prevent injuries are an important health priority in this vulnerable population. This paper reviews evidence from injury prevention studies for people with ID and also considers the relevance of general population injury interventions for this population. METHOD: Information regarding injury prevention in both ID and general populations was identified using online systems and consultation with research and public health organizations. RESULTS: Few published studies were identified addressing the issue of injury prevention for those with ID. Possible injury prevention strategies appropriate for the major causes of injury in the ID population were identified from the general population literature. While many environmental injury prevention strategies for young children in the general population are applicable to the population with ID, some may require design modification to ensure effectiveness. Other promising approaches include improved information for parents/carers, primary care physician counselling, and home visits by well-informed and motivated professionals. There may be injury prevention benefit from improved management of psychopathology and epilepsy. CONCLUSIONS: The issue of injury prevention for those with ID has not been addressed to the extent that the magnitude of the problem requires. Injury prevention programmes trialling a variety of evidence-based approaches and strategies are needed to protect the quality of life for the ID population and their families.

Injury prevention during physical activity in the Australian Defence Force.

INTRODUCTION: Injuries sustained by Australian Defence Force (ADF) personnel during non-combat military training and sports activity are associated with increasing costs due to work days lost, medical treatment, compensation, and early retirement. In 2001, the ADF commissioned a systematic review of the evidence-base for reducing injuries associated with physical activity, while at the same time improving physical activity participation rates to sustain a trained, fit and deployable workforce. METHOD: Literature from on-line library databases, relevant unclassified military reports, and material from previously published sport-specific injury countermeasure reviews were systematically and critically analysed to address the study aims. RESULTS: Modification of intensity, frequency and duration of basic military training activities and improved equipment is likely to reduce injury occurrence. Sports injury countermeasures used for the civilian population have merit for the ADF physical activity program. Injury countermeasures should be designed to minimise any possible deterrent effect on the motivation to participate in regular physical activity. Increasing the participation of ADF personnel in physical activity in the presence of evidence-based injury prevention strategies has the potential to increase health, fitness and deployability with minimal impact on injury frequency. CONCLUSION: Recommendations arising from the review include injury intervention trials in basic military training and sports. These and other interventions should be supported by refinement to ADF injury surveillance systems. Research should focus on interventions with the greatest gain for fitness, deployability, and cost effectiveness.

Controlled evaluation of a community based injury prevention program in Australia.

OBJECTIVE: To evaluate the effects of a community based, all age, all injury prevention program, the Safe Living Program, on injury risk and injury rates. DESIGN: A quasiexperimental population based evaluation using an intervention and comparison community design. SETTING: The intervention community (Shire of Bulla, n = 37,257) is an outer metropolitan area of Melbourne, Australia. The demographically matched comparison community (Shire of Melton, n=33,592) is located nearby. SUBJECTS AND METHODS: The Safe Living Program in the Shire of Bulla targeted injury reduction in all settings with a focus on high risk groups. Strategies included program publicity, education and training, injury hazard reduction, and environmental change. Baseline and follow up measures of program reach, risk factors, and injury rates in both communities were used to evaluate program process, impact, and outcome. RESULTS: Increase in program awareness was moderate and similar to other community based programs. The program achieved injury hazard reduction on the road, in schools, and, to a more limited extent, in the home. Other changes in injury risk factors could not necessarily be attributed to the program as similar changes were observed in the comparison community. No significant changes were found in rates of injury deaths, hospitalisations, or emergency department presentations in the Shire of Bulla after six years. Self reported household injuries, mostly minor, were reduced in the intervention community, but had been higher at program launch than in the comparison community. CONCLUSIONS: The Safe Living Program was unable to replicate the significant reductions in injuries reported in other community based interventions. Replication of apparently successful community based injury prevention programs in different settings and populations requires evidence based interventions, sustained and effective program penetration, reliable data systems to measure change, at least one control community, and sufficient budget and time for effects to be observable.

Injury risk in young people with intellectual disability.

Epidemiological studies have established injury as a major public health problem for young people in the general population, but minimal population-based injury information exists on those with intellectual disability (ID). The present study investigated risk factors for injury to subjects in the Australian Child and Adolescent Development (ACAD) programme, which is examining emotional and behavioural problems in young people with ID. Extensive biopsychosocial data for the ACAD programme were collected at two time intervals (i.e. 1990-1991 and 1995-1996). Carer report of medically attended injury over one year was collected for the first time period (1995-1996) on a sample of 465 ACAD subjects (aged 5-29 years) representative of young people with ID (IQ < 70) to determine risk factors for injury using the ACAD biopsychosocial data. Psychopathology [odds ratio (OR)=3.4] epilepsy (OR = 2.4) and an overly sociable temperament (OR=2.2) are associated with injury in young people with ID. Social and family factors had minimal influence on injury risk in this population. Those who are highly disruptive, self-absorbed, anxious, have problems relating socially, have communication disturbance or have attention deficit hyperactivity symptoms are particularly at increased risk for injury. The present study demonstrates a largely under-recognized public health problem of a high unintentional injury risk for young people with ID, and identifies substantial and important risk factors for injury. Injury prevention programmes, with a particular focus on those with highly disturbed behaviours or epilepsy, are warranted in this population.

Injury in young people with intellectual disability: descriptive epidemiology.

OBJECTIVES: To assess the public health importance of injury in a representative sample of young people with intellectual disability relative to the general population. SETTING: This study forms part of the Australian Child and Adolescent Development (ACAD) program examining emotional and behavioural problems in a cohort of young people with intellectual disability (IQ<70). The program has collected extensive biopsychosocial data from carers of subjects at two time intervals, 1990 (n = 579) and 1996 (n = 465). METHOD: Carer report of medically attended injury to subjects was collected for the first time during 1996 (age 5-29 years) and supplemented with medical record injury data from hospitals and general practitioners for 147 of the ACAD sample and 110 supplementary subjects. These data were compared with general population injury data to assess relative epidemiological differences. RESULTS: Annual injury mortality and morbidity rates were 150/100,000 and 55.6/1000 persons, with age standardised mortality and morbidity ratios of 8 and 2 respectively. Males and females had similar injury rates. The rate for injury hospitalisations was twice that of the general population. Falls were more common and transport injury and intentional injury less common causes of injury morbidity compared with general population. The patterns of cause, circumstances, and severity of injury in young people with intellectual disability have more similarities with younger children than with their same age group in the general population. CONCLUSION: This study should alert clinicians and others to the increased risk for injury and possible further handicap in this population. It is essential that injury prevention programs be implemented and evaluated for their effectiveness in reducing the substantial additional burden of suffering, care and cost resulting from injury to young people with intellectual disability.