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.

Are virtual consultations suitable for patients with vulval disease? A multicentre audit of outcomes in the COVID-19 pandemic.

Background: During the COVID-19 pandemic, virtual consultation (VC) was used to replace in-person consultations. This raises specific questions when dealing with vulval conditions. Objectives: To assess the feasibility and the efficiency of VC with and without supplementary imaging, in patients with vulval conditions, and to evaluate the images provided as an aid to diagnosis. Methods: This prospective multicentre audit took place in three specialized vulval clinics in London and Paris. Anonymized data on patients' clinical characteristics, consultation characteristics (including the number and quality of any supplementary images provided) and consultation outcomes (diagnostic certainty and physician satisfaction) were collected. Characteristics and outcomes in those with or without supplementary imaging were compared amongst both new and follow-up consultations. Results: A total of 316 VCs were included. In total, 18.7% (n = 59) were new patient consultations and 81.3% (n = 257) were follow-up. Supplementary imaging (photographs and/or video recordings) were provided by 28.5% (n = 90) of the total cohort. Median photographic quality was significantly higher on a five-point Likert-type scale when photographs were taken by a third party as opposed to the patient themselves (4 vs. 3, Mann-Whitney U-test, p < 0.0001). There was no association between the provision of supplementary imaging and diagnostic certainty amongst new patient consultations. However, a higher proportion of follow-up patients who provided supplementary imaging received definitive management decisions (χ 2 test, p < 0.001) and physician satisfaction with these consultations, as measured on a five-point Likert-type scale, was significantly higher (Mann-Whitney U-test, p < 0.0001). Furthermore, median physician satisfaction scores ≥4 were observed in follow-up consultations for candidiasis, lichen simplex/eczema and vulvodynia. Conclusions: Although in-person consultation remains the gold standard of care, VC may have a role in the management of selected patients with vulval disease. It is possible to provide good-quality photographs for clinical assessment, particularly with the help of a third party and follow-up patients with an established, cancer-unrelated diagnosis may be best suited for this consultation modality.

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.

Subungual melanoma with blue naevus-like morphological features: a clinicopathological retrospective analysis of nine cases.

Melanocytic lesions in the nail apparatus are often challenging. Both subungual melanomas (SUM) and blue naevus of the nail are very rare. Occasionally, melanomas may mimic blue naevus histologically. Benign and malignant blue melanocytic lesions are commonly associated with G protein mutations, a distinct abnormality not associated with conventional subungual melanomas. We describe the clinical, histological and immunohistochemical features of nine cases of SUM with blue naevus-like morphological features. Mutations in exon 4 and 5 of GNAQ and GNA11 were investigated in two cases, which showed no mutations. RNA-seq of one case revealed unknown mutations along with mutations in ATM, METK and ARID1A. Our study delineates a variant of SUM that mimics blue naevus. Awareness of this pitfall is important when evaluating heavily pigmented lesions around the nail in order to avoid misdiagnosis. Appropriate sampling of subungual lesions and clinicopathological correlation are paramount to reach the correct diagnosis.

The role of psychological flexibility, perceived injustice and body image in Vulvodynia: A longitudinal study.

BACKGROUND: Women with Vulvodynia experience pain, related impacts on sex and daily functioning, and depression. While psychosocial factors are associated with outcomes in Vulvodynia, longitudinal data are limited, especially in mixed/spontaneous Vulvodynia. Broad psychological models such as psychological flexibility (PF) and content-specific factors, such as body-exposure anxiety (BEA) and avoidance during sexual activities and perceived injustice, have not been adequately investigated in Vulvodynia. The aim of this study was to explore whether these factors assessed at baseline predict pain severity, pain interference, sexual functioning and satisfaction and depression 3 months later. METHODS: A longitudinal study of 349 women with Vulvodynia was conducted. Participants completed online self-report measures of pain-related and sexual outcomes, depression, BEA, perceived injustice and facets of PF (present moment awareness, pain acceptance, committed action) at baseline and after 3 months, overlapping with the Coronavirus disease 2019 (COVID-19) pandemic. RESULTS: Seventy percent of women responded at both assessments (n = 244). There were significant decreases in pain severity, pain interference, present moment awareness, committed action and a significant increase in depression at 3 months. All the baseline psychosocial factors significantly correlated with at least one outcome at 3 months. When adjusting for baseline outcome and demographics, committed action significantly positively predicted depression at 3 months and pain acceptance significantly positively predicted pain interference at 3 months. CONCLUSIONS: Among women with Vulvodynia, pain acceptance and committed action are prospectively associated with pain interference and depression. The reliability and generalizability of these results needs to be established given the overlap with the COVID-19 pandemic. Future studies should investigate whether targeting these factors enhances outcomes in Vulvodynia. SIGNIFICANCE: This longitudinal study explored the role of PF, perceived injustice and body image during sexual activities in predicting pain severity, pain interference, sexual functioning, sexual satisfaction and depression in women with Vulvodynia. The study findings reveal that two facets of PF (committed action and pain acceptance) predicted pain interference and depression over time. It may be important to incorporate these processes in treatments developed for Vulvodynia.

"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 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.

Anogenital Crohn's Disease and Granulomatosis: A Systematic Review of Epidemiology, Clinical Manifestations, and Treatment.

BACKGROUND AND AIMS: Metastatic Crohn's disease is an extraintestinal cutaneous manifestation characterised by non-specific inflammatory lesions anatomically separate from the gut; genital involvement is rare. We conducted a systematic review of anogenital Crohn's disease and granulomatosis, to provide a synthesis of epidemiology, clinical features, and treatment outcomes. METHODS: A systematic search of the literature was conducted via MEDLINE, EMBASE, and the Cochrane database from inception to December 1, 2020. Two investigators extracted and analysed study data. Response and remission were defined as partial improvement or complete resolution of symptoms and examination findings, respectively. RESULTS: Of 9381 screened studies, 185 articles, [410 cases: 273 female, 137 male] were included. The predominant clinical features were oedema, ulcers, fissures, and hypertrophic lesions. Adults and children present similarly. Luminal Crohn's disease was diagnosed in nearly 80% of cases including 45-80% patients without gastrointestinal symptoms (time to inflammatory bowel disease [IBD] from anogenital Crohn's disease diagnosis [range] -43 to 11 years). Antibiotics, corticosteroids, thiopurines, and anti-tumour necrosis factor [TNF] therapy were the most frequently prescribed agents. At final follow-up, non-response, response, and remission rates were 37/304 [12%], 267/304 [88%], and 114/304 [38%], respectively. Oedema was associated with a poor response to topical therapy. Greater response rates to anti-TNF therapy were seen in patients prescribed concomitant immunomodulation [24/25, 96% vs 67/90, 74%, p = 0.02]. CONCLUSIONS: We provide an illustrative summary of the clinical presentation and treatment effectiveness of this rare, under-recognised condition, and a proposed algorithm for approach and management. Prospective studies with longer follow-up are required to define optimal treatment strategies.

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.

Complete Genome Sequence of the Cluster B4 Mycobacteriophage Lolalove, Isolated in Charleston, South Carolina.

Lolalove, a B4 subcluster soil bacteriophage of Mycobacterium smegmatis, was isolated in Charleston, SC. It possesses a 71,111-bp linear double-stranded DNA (dsDNA) genome with 99 protein-coding genes and a GC content of 68.9%. genome BLASTn alignments indicate high sequence identity to the related B4 subcluster M. smegmatis phages BrownCNA, Mithril, and Hangman.

Avid binding by B cells to the Plasmodium circumsporozoite protein repeat suppresses responses to protective subdominant epitopes.

Antibodies targeting the NANP/NVDP repeat domain of the Plasmodium falciparum circumsporozoite protein (CSPRepeat) can protect against malaria. However, it has also been suggested that the CSPRepeat is a decoy that prevents the immune system from mounting responses against other domains of CSP. Here, we show that, following parasite immunization, B cell responses to the CSPRepeat are immunodominant over responses to other CSP domains despite the presence of similar numbers of naive B cells able to bind these regions. We find that this immunodominance is driven by avid binding of the CSPRepeat to cognate B cells that are able to expand at the expense of B cells with other specificities. We further show that mice immunized with repeat-truncated CSP molecules develop responses to subdominant epitopes and are protected against malaria. These data demonstrate that the CSPRepeat functions as a decoy, but truncated CSP molecules may be an approach for malaria vaccination.

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.

Evaluation of health promotion capacity gains in a state-wide rural food literacy intervention.

Building capacity to enhance health promotion intervention effectiveness is a desirable, difficult to achieve and rarely evaluated aspect of practice. This study aims to describe an approach for evaluating capacity building embedded in a state-wide health promotion intervention that had a primary objective of enhancing food literacy and secondary objective of building health promotion capacity. The multi-strategy rural food literacy intervention centred on a group-based, hands-on learning workshop series. Logic modelling, theory of change and clarification of the explicit assumption of the intervention relating to food literacy and capacity building objectives were documented. The evaluation approach acknowledged the complexity of the intervention that utilised a food literacy program as a vessel to build relationships, enabling capacity-building strategies over time, and used multiple forms of data to measure organisational, community and individual capacity. The development of a shared mixed method program evaluation plan was achieved through co-design. One-hundred and twenty-two peer facilitators were trained across 81 communities and reported increases in self-efficacy for health promotion action. There was broad awareness and support for the program within the organisation. The majority (75%) of communities involved in the intervention implemented at least one health promotion activity, demonstrating some health promotion capacity gain.