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).

Erosive vulval lichen planus--a diagnosis not to be missed: a clinical review.

Lichen planus is one of the inflammatory dermatoses that have a predilection for the genital mucosa, and the erosive type is particularly important. This can also affect other mucosal sites and scarring may occur, leading to significant symptoms and an effect on quality of life for patients. There is often a delay before the correct diagnosis is made and appropriate treatment instituted. This clinical review covers the clinical features and management options for this important disease and emphasises the need for a multi-disciplinary approach.

Reduced N400 semantic priming effects in adult survivors of paediatric and adolescent traumatic brain injury.

The immediate and long-term neural correlates of linguistic processing deficits reported following paediatric and adolescent traumatic brain injury (TBI) are poorly understood. Therefore, the current research investigated event-related potentials (ERPs) elicited during a semantic picture-word priming experiment in two groups of highly functioning individuals matched for various demographic variables and behavioural language performance. Participants in the TBI group had a recorded history of paediatric or adolescent TBI involving injury mechanisms associated with diffuse white matter pathology, while participants in the control group never sustained any insult to the brain. A comparison of N400 Mean Amplitudes elicited during three experimental conditions with varying semantic relatedness between the prime and target stimuli (congruent, semantically related, unrelated) revealed a significantly smaller N400 response in the unrelated condition in the TBI group, indicating residual linguistic processing deviations when processing demands required the quick detection of a between-category (unrelated) violation of semantic expectancy.

Long-term follow-up of patients with lichen sclerosus: does it really happen?

Lichen sclerosus is a common condition affecting the vulva and long-term follow-up is recommended. We audited a group of patients discharged from the vulval clinic and found that 38% had not seen their GP 12 months after discharge. Of those that were seen, 17% were not examined. Further education is needed to improve the follow-up of these patients.

A retrospective study of the referral patterns to a vulval clinic: highlighting educational needs in this subspecialty.

A retrospective study of the referral patterns to a specialist vulval clinic was performed. A total of 200 clinical records were reviewed of new patients seen between January 2004 and June 2005. A provisional diagnosis was stated in 45.5% of referrals, of which 27.5% had the diagnosis changed at the clinic. The majority of referrals were from general practitioners (GPs) (77%) and smaller proportions from gynaecologists (11%), dermatologists (9%) and others (3%). The most common conditions seen were lichen sclerosus (39%), eczema/lichen simplex (30.5%), lichen planus (11.5%), pain syndromes (10.5%) and others (8.5%). Lichen sclerosus was accurately diagnosed in 54.5% of referrals but for eczema/lichen simplex it was only recognised in 11.5% of referrals. Nine cases of lichen sclerosus had been referred by gynaecologists after histological confirmation, for advice on management. Education of vulval diseases to non-specialists should focus on conditions that they are most likely to encounter and find difficult to manage. This study illustrates an effective method to define what the local teaching requirements are.

Treatment of vulval Crohn's disease with infliximab.

Anti-tumour necrosis factor-alpha therapy of Crohn's disease (CD) with infliximab has proved a major advance in the treatment of patients with difficult disease. We report our experience of the use of infliximab in a patient with recalcitrant vulval CD. The introduction of infliximab has improved disease control, although a search for an optimum remittive dosing schedule is ongoing.

Theoretical development of nursing interventions for sudden cardiac arrest survivors using social cognitive theory.

This article discusses the theoretical development of a nursing intervention program to enhance recovery over the first year following sudden cardiac arrest. Concepts from social cognitive theory and domains of concern following sudden cardiac arrest underpin a tailored and standardized nursing intervention. The nursing intervention program is designed for delivery by means of telephone and through the mail. Testing of the nursing intervention program is underway using a clinical trial design.

Contact sensitivity to nickel and other metals in jewelry reactors.

BACKGROUND: Many patients who give a history of a dermatitis reaction to jewelry or metal contact with skin are negative to metals on standard patch testing. Some may be showing false-negative reactions. OBJECTIVE: Our purpose was to determine whether patients with a history of jewelry reactions but whose standard patch tests were negative have a false-negative reaction or are allergic to metals other than nickel, cobalt, or chromium. METHODS: Four hundred forty-nine patients were studied who gave a history of reacting to jewelry or metal. Of these, 210 were tested to the metals in the European standard series (ie, nickel, cobalt, and chromate), and 239 were tested to the metals in the standard series and to an extended metal series of palladium, gold, platinum, a second nickel salt, and a nickel/cobalt mixture. These were compared with 752 patients who did not give a history of jewelry or metal reactions, of which 50, besides the standard series, were also treated with the additional metal series. RESULTS: A higher proportion of jewelry-reactive patients tested with the extended series reacted to nickel (and to other metals) than those who were tested only with the European standard series: (61% vs 38%; P <.0001 ). The use of the extended series showed that palladium allergy was common, present in 34% of nickel-allergic patients, but it always occurred with nickel sensitivity. Gold allergy coexisted with nickel sensitivity in 10% of cases. Testing simultaneously with separate patches containing 5% nickel sulfate and 5% nickel chloride showed a concordance of 71% in identified nickel-sensitive patients. Nickel sulfate was more likely than nickel chloride to detect nickel sensitivity. The use of a combined preparation of 2.5% nickel sulfate and 0.5% cobalt chloride in petrolatum revealed only 3 jewelry-reactive patients who were negative to other metals. There was a slightly higher proportion of atopic patients in the patch test-negative jewelry reactors group than in the positive group; however, the difference was not significant and it was not sufficient to account for the negative findings. CONCLUSION: Some jewelry reactors who had negative patch tests are likely to be subclinically allergic to nickel. We suggest that the higher number of antigens, or perhaps the larger nickel load, in the extended metal series, resulted in a larger proportion of patients reacting. To better demonstrate nickel allergy in jewelry reactors, patients should be patch tested to a metal series that contains palladium and gold salts and perhaps a second nickel patch because these may reveal the presence of nickel sensitivity when standard patch tests would otherwise have been negative.

Mother and child interactions about the mother's breast cancer: an interview study.

PURPOSE/OBJECTIVES: To describe mothers' reported methods of interacting with the mothers' school-age children about their breast cancer. DESIGN: Qualitative. SETTING/SAMPLE: 19 mothers newly diagnosed with breast cancer. Mothers received treatment for their illness in the Pacific Northwest. Mothers had at least one child between 7 and 12 years old at the time of diagnosis. METHODS: Case-intensive, in-home, semistructured interviews were audiotaped, transcribed, and inductively coded into four conceptual domains and 16 categories of behavioral strategies used by the mothers to interact with their children about the breast cancer. MAIN RESEARCH VARIABLES: Behavioral strategies used by mothers when interacting with the children about the breast cancer and when providing children with support. FINDINGS: Mothers used a number of methods to bring children into the mothers' breast cancer experience. The conceptual domains included talking about the breast cancer, explaining treatment and care, providing experiences, and doing things to help children cope. CONCLUSIONS: The dominant pattern in the interview data was for mothers to assume a teacher/educator role with the children about the cancer, not an interactive, emotive-expressive parenting role. Most mothers used technical biomedical language; did not give evidence of systematically checking on the children's understanding of what they were told; did not elicit the children's concerns; and exposed the children to emotionally laden or potentially frightening images, words, or experiences. IMPLICATIONS FOR NURSING PRACTICE: Programs and materials need to be developed that help mothers work from a model of parenting that includes developmentally appropriate language, facilitates the children's expression of questions and feelings, links the mothers with the children's understanding of the illness, and assists the children to better manage what is happening related to the breast cancer.