Development and Validation of a Clinical Grading Scale to Assess the Vulvar Region: The Vulvar Architecture Severity Scale.

BACKGROUND: The vulva is composed of aesthetic units that can be affected differently by vulvar conditions. A reliable, comprehensive, and quick-to-use clinical scoring system is required to assess the disease extent in the vulvar area. OBJECTIVES: The aim of this study was to develop and validate a grading scale based on the aesthetic unit principle to evaluate the extent of vulvar lichen sclerosus (VLS). METHODS: After reviewing photographs of 100 patients affected by VLS, the authors targeted the aesthetic units most frequently affected. The disease signs were recorded and graded in 4 levels of severity (none, mild, moderate, severe) taking into account the vulvar architecture and skin involvement. To validate the scale, 14 observers were asked to apply it to photographs of 25 VLS patients on 2 different occasions. Intra- and inter-observer reliabilities were determined employing Pearson's and intraclass correlation coefficients. RESULTS: A 6-region, 4-point grading system was designed and identified as the Vulvar Architecture Severity Scale (VASS). In all 6 areas, the Pearson's r was greater than 0.9 (mean, 0.994; 95% confidence interval [CI] = 0.992), indicating that the intra-observer reliability of the VASS was consistent over time (P < 0.001). Intraclass correlation at time 1 was 0.928 (95% CI = 0.910, 0.943) and at time 2 was 0.944 (95% CI = 0.931, 0.996), indicating a high reliability level among different observers. CONCLUSIONS: The VASS is a reliable scale to assess the severity of VLS, and it might be considered as an outcome measure in future VLS trials.

Fat Grafting Improves Fibrosis and Scarring in Vulvar Lichen Sclerosus: Results From a Prospective Cohort Study.

OBJECTIVE: The aim of the study was to evaluate the effect of lipotransfer in women presenting with fibrosis and scarring due to lichen sclerosus. MATERIALS AND METHODS: This prospective cohort study included 33 women attending the vulvar clinic of a public hospital. Patients received one lipotransfer treatment. Validated measures were used prospectively to assess the sexual function (Female Sexual Function Index, Female Sexual Distress Scale); symptoms (visual analog scale for itching, burning, soreness), pain (Pain Anxiety Symptoms Scale 20); psychological status and quality of life (Hospital Anxiety and Depression Scale, Relationship Assessment Scale, Wound Management Questionnaire Revised); physician-based disease signs (Vulvar Architecture Severity Scale). Data were analyzed using paired t test with nonparametric Wilcoxon matched-pairs signed rank test and unpaired t test with nonparametric Mann-Whitney test (Prism6 Software). RESULTS: The mean (SD) follow-up was 12.9 (3.5) months. Sexual function improved after treatment (p < .001), as well as the distress associated with sexuality (p < .0001). A significant improvement was reported in itching (p < .001), burning (p < .05), soreness (p < .001), and pain (p < .0001). Patients reported a significant improvement in romantic relationship (p < .05), anxiety (p < .0001), and depression (p < .0001). Improvement was not significant in the self-care associated with self-disgust assessment (p = .42). The clinical physician-based score showed an overall improvement in all the treated areas to lesser or greater extent. CONCLUSIONS: The use of fat grafting in lichen sclerosus is promising. Further studies are required to rule out a potential placebo effect and to better understand the underlying molecular mechanism of action.

Protected training time is essential for patient safety.

The Commission on Education and Training for Patient Safety has recommended that Health Education England (HEE) review mandatory training and the delivery of continuing professional development (CPD) relating to patient safety (news, March 16). All staff and trainees need to be empowered to raise concerns and they need support from managers to learn about and improve patient safety.

Objective Structured Assessment of Technical Skill in assessing technical competence to carry out caesarean section with increasing seniority.

Since the incorporation of workplace-based assessment within the specialty training programme in obstetrics and gynaecology, the assessment of technical competence to carry out caesarean section has been undertaken by the Objective Structured Assessment of Technical Skill tool. This requirement has been formalised in the Matrix of Educational Progression, ensuring that the tool must assess trainees' technical competence in caesarean section procedures of varying levels of complexity throughout training. Trainee feedback suggests that the effectiveness of the tool diminishes as the seniority of the trainee increases, with technical competence assessed less effectively in more complex procedures. This seems to be a result of the generic design of the tool and insufficient training on the part of assessors. Both of these are due to be addressed within a division of the Objective Structured Assessment of Technical Skill tool into explicitly formative and summative assessments of technical skill, following a General Medical Council-led consultation on the future of workplace-based assessment.

Sustained survival and maturation of adult neural stem/progenitor cells after transplantation into the injured brain.

Multipotent neural stem/progenitor cells (NS/NPCs) that are capable of generating neurons and glia offer enormous potential for treating neurological diseases. Adult NS/NPCs that reside in the mature mammalian brain can be isolated and expanded in vitro, and could be a potential source for autologous transplantation to replace cells lost to brain injury or disease. When these cells are transplanted into the normal brain, they can survive and become region-specific cells. However, it has not been reported whether these cells can survive for an extended period and become functional cells in an injured heterotypic environment. In this study, we tested survival, maturation fate, and electrophysiological properties of adult NS/NPCs after transplantation into the injured rat brain. NS/NPCs were isolated from the subventricular zone of adult Fisher 344 rats and cultured as a monolayer. Recipient adult Fisher 344 rats were first subjected to a moderate fluid percussive injury. Two days later, cultured NS/NPCs were injected into the injured brain in an area between the white matter tracts and peri-cortical region directly underneath the injury impact. The animals were sacrificed 2 or 4 weeks after transplantation for immunohistochemical staining or patch-clamp recording. We found that transplanted cells survived well at 2 and 4 weeks. Many cells migrated out of the injection site into surrounding areas expressing astrocyte or oligodendrocyte markers. Whole cell patch-clamp recording at 4 weeks showed that transplanted cells possessed typical mature glial cell properties. These data demonstrate that adult NS/NPCs can survive in an injured heterotypic environment for an extended period and become functional cells.

Deficits in muscle strength, mass, quality, and mobility in people with chronic obstructive pulmonary disease.

PURPOSE: Midthigh intramuscular fat (IF), a feature of reduced muscle quality, is an important predictor of self-reported mobility loss in the elderly. This study compared measures of muscle strength, mass, IF, and mobility in patients with chronic obstructive pulmonary disease (COPD) and healthy subjects. Associations between measures of muscle strength, mass, IF, and mobility were explored. METHODS: Knee extensor muscle strength was assessed with an isokinetic dynamometer. Cross-sectional area and IF of the thigh muscles were measured with computerized tomography. Mobility was assessed with the repetitive sit-to-stand, self-selected gait speed, and 6-minute walk tests. RESULTS: Patients with COPD (n = 21, age 71.3 ± 8.1 years, and a percentage predicted force expiratory volume in 1 second of 47.2 ± 12.9) and 21 healthy subjects matched for age (67.4 ± 8.6 years), gender, and body mass participated in the study. Patients with COPD showed reduced average knee extensor strength (29%, P = .016) cross-sectional area of the thigh muscles (17%, P = .007) and mobility measures (~23%, P ≤ .001). Knee extensor and flexor IF was 2-folds greater in people with COPD (P ≤ .005). Measures of knee extensor muscle strength, mass, and IF were not associated with mobility measures. CONCLUSIONS: Compared with healthy controls, patients with moderate to severe COPD show marked deficits in muscle strength, mass, quality, and mobility. More studies with larger sample size are required to elucidate whether any of these muscle deficits can explain mobility impairments in COPD.

The development of a new speciality training programme in obstetrics and gynaecology in the UK.

In 2004, the Royal College of Obstetricians and Gynaecologists (RCOG) established a working group of experienced Fellows, Members, trainees and educationalists, who were responsible for writing and coordinating the development of a new curriculum in obstetrics and gynaecology. The curriculum would underpin the new 7-year speciality training programme. In December 2006, the UK Postgraduate Medical Education and Training Board approved the curriculum. In August 2007, the new Speciality Training and Education programme in Obstetrics and Gynaecology was launched. The curriculum forms the backbone of the 7-year speciality training programme in obstetrics and gynaecology. The programme is divided into three levels of training: basic, intermediate and advanced. The programme is competency-based rather than being focussed on time periods or the number of hours or number of procedures required to progress through the programme. Successful progress is achieved by meeting the requirements at designated waypoints defined within the programme. The curriculum outlines not only the knowledge and technical clinical skill requirements, but also the professional skills and attitudes that must consistently be adopted by health-care professionals in a modern health service. The curriculum was originally benchmarked against the General Medical Council's Good Medical Practice criteria: (1) Good clinical care; (2) Good medical practice; (3) Successful relationships with patients; (4) Working with colleagues; (5) Teaching and training; (6) Probity; (7) Health.

Strain-related differences after experimental traumatic brain injury in rats.

The present study directly compares the effects of experimental brain injury in two commonly used rat strains: Fisher 344 and Sprague-Dawley. We previously found that Fisher rats have a higher mortality rate and more frequent seizure attacks at the same injury level than Sprague-Dawley rats. Although strain differences in rats are commonly accepted as contributing to variability among studies, there is a paucity of literature addressing strain influence in experimental neurotrauma. Therefore this study compares outcome measures in two rat strains following lateral fluid percussion injury. Fisher 344 and Sprague-Dawley rats were monitored for changes in physiological measurements, intracranial pressure, and electroencephalographic activity. We further analyzed neuronal degeneration and cell death in the injured brain using Fluoro-Jade-B (FJB) histochemistry and caspase-3 immunostaining. Behavioral studies using the beam walk and Morris water maze were conducted to characterize strain differences in both motor and cognitive functional recovery following injury. We found that Fisher rats had significantly higher intracranial pressure, prolonged seizure activity, increased FJB-positive staining in the injured cortex and thalamus, and increased caspase-3 expression than Sprague-Dawley rats. On average, Fisher rats displayed a greater amount of total recording time in seizure activity and had longer ictal durations. The Fisher rats also had increased motor deficits, correlating with the above results. In spite of these results, Fisher rats performed better on cognitive tests following injury. The results demonstrate that different rat strains respond to injury differently, and thus in preclinical neurotrauma studies strain influence is an important consideration when evaluating outcomes.

Effects of exercise training and inspiratory muscle training in spinal cord injury: a systematic review.

OBJECTIVE: To provide a systematic review of the studies assessing exercise training and inspiratory muscle training (IMT) in individuals for the improved respiratory function of patients with spinal cord injury (SCI). METHODS: Thirteen studies (5 exercise training, 8 IMT) were identified. Articles were scored for their methodological quality using the Physiotherapy Evidence Database scores and Downs and Black tools for randomized and nonrandomized studies, respectively. Conclusions were based on the most rigorously executed studies using Sackett's levels of evidence. RESULTS: Study comparison was compromised by diverse research designs; small sample sizes; and heterogeneity of studied populations, protocols, and outcome measures. Based on current literature, there is level 2 evidence supporting exercise training as an intervention to improve respiratory strength and endurance and level 4 evidence to support exercise training as an intervention that might improve resting and exercising respiratory function in people with SCI. There is level 4 evidence to support IMT as an intervention that might decrease dyspnea and improve respiratory function in people with SCI. CONCLUSIONS: There are insufficient data to strongly support the use of exercise training or IMT for improved respiratory function in people with SCI. There is some evidence of efficacy of both regimens; however, the evidence is not of the best possible quality.

Post-injury atomoxetine treatment improves cognition following experimental traumatic brain injury.

Catecholaminergic neurotransmission is regionally altered following injury, and drugs aimed at these systems offer promising avenues for post-traumatic brain injury (TBI) pharmacotherapies. Atomoxetine is a selective norepinephrine transporter (NET) inhibitor currently indicated for treatment of attention-deficit hyperactivity disorder (ADHD). The current study was designed to test the efficacy of atomoxetine in treating cognitive deficits following experimental TBI in animals and to determine an optimal dose and therapeutic window for drug treatment. Sprague-Dawley rats were subjected to lateral fluid-percussion injury (L-FPI) of moderate severity (2.08 atm +/- 0.05). Two experiments were performed. In the first study, atomoxetine (0.3, 1, 3, or 9 mg/kg) or vehicle was administered daily on post-injury days (PID) 1-15. Cognitive assessment was performed using the Morris water maze on PID 11-15. L-FPI resulted in significant cognitive impairment when compared to Sham-Injury. Treatment with lower doses of atomoxetine (0.3, 1, and 3 mg/kg) significantly attenuated the cognitive deficits in injured animals. Treatment with the higher dosage (9 mg/kg) of atomoxetine resulted in animals that were not significantly different than injured-vehicle treated animals. The optimal response was achieved using 1 mg/kg atomoxetine. In the second study, treatment with atomoxetine (1 mg/kg) or vehicle was delayed for 11 days post-injury. Rats were administered atomoxetine daily for 15 days, and cognitive assessment was performed on PID 25-29. In this study, treatment with atomoxetine (1 mg/kg) did not result in improved cognitive performance. In conclusion, this is the first study to show low-dose atomoxetine initiated early after experimental TBI results in improved cognition.

Is localized, provoked vulvodynia an inflammatory condition?

OBJECTIVE: To perform a pilot study to investigate the relationship between localized, provoked vulvodynia of the vestibule and inflammatory cytokine expression. STUDY DESIGN: Women with a diagnosis of localized, provoked vulvodynia had tissue samples taken for vulvar expression of Interleukin 1alpha and 1beta and tumor necrosis factor alpha and compared to those of a control group. RESULTS: The study group did not show a significant increase in expression of inflammatory markers. CONCLUSION: There was no evidence in this study that localized, provoked vulvodynia is an inflammatory condition, as previously thought. This may be helpful in explaining why some women are resistant to medical or antiinflammatory treatment and may allow treatment to be prescribed more effectively.

Insulin-like growth factor-1 gene splice variants as markers of muscle damage in levator ani muscle after the first vaginal delivery.

OBJECTIVE: Studies in animals and human muscle have demonstrated differential splicing of the insulin-like growth factor-1 gene in response to mechanical strain and damage. We conducted a study on the expression of insulin-like growth factor-1 splice variants in the levator ani muscle after the first vaginal delivery. STUDY DESIGN: Ten women were recruited after the first vaginal delivery. Biopsy specimens were taken vaginally of the pubovisceral component of the levator ani muscle. Five nonpregnant women were recruited as control subjects. Samples were processed with real-time quantitative polymerase chain reaction, with specific primers for the insulin-like growth factor-1 splice variants. RESULTS: Insulin-like growth factor splice variants mechano growth factor and insulin-like growth factor-1Ea were significantly up-regulated (100- and 1000-fold) in the delivery population, compared with control subjects (P=.012 and .04, respectively). Statistical analysis indicated a correlation between the expression of the insulin-like growth factor-1 splice variants and the length of the second stage. CONCLUSION: These results show that damaged levator ani muscle results from stretch and overload after the first vaginal delivery.

The impact of poster advertising in buses on young people's awareness and knowledge of a telephone counselling service.

OBJECTIVE: To evaluate the impact of a public poster advertising campaign for Kids Help Line, a national Australian telephone counselling service providing young people with 24-hour access to trained counsellors. METHODS: Posters were displayed in the interior of 50% of all Brisbane City Council buses for a period of six months. 1,642 high school students were surveyed at the end of the campaign to determine their awareness and knowledge of Kids Help Line services. Awareness and knowledge of frequent bus users was compared with that of non-bus users and the linear relationship between bus usage and awareness and knowledge was investigated. RESULTS: After controlling for age, socio-economic status and gender effects, there was evidence of a linear relationship between exposure to advertisements and expectation that Kids Help Line could assist with a larger range of problems. There was a trend towards a relationship between exposure and knowledge of Kids Help Line. CONCLUSIONS AND IMPLICATIONS: Although effect size was small, the results suggest that the advertising campaign had a modest but potentially important impact.

Automatic message handling for a national counselling service.

An automatic email handling system (AutoRouter) was introduced at a national counselling service in Australia. In 2003, counsellors responded to a total of 7421 email messages. Over nine days in early May 2004 the administrator responsible for the management of the manual email counselling service recorded the time spent on managing email messages. The AutoRouter was then introduced. Since the implementation of the AutoRouter the administrator's management role has become redundant; an average of 12 h 5 min per week of staff time has been saved. There have been further savings in supervisor time. Counsellors were taking an average of 6.2 days to respond to email messages (n = 4307), with an average delay of 1.2 days from the time counsellors wrote the email to when the email was sent. Thus the response was sent on average 7.4 days after receipt of the original client email message. A significant decrease in response time has been noted since implementation of the AutoRouter, with client responses now taking an average of 5.4 days, a decrease of 2.0 days. Automatic message handling appears to be a promising method of managing the administration of a steadily increasing email counselling service.

Achieving compliance with the European Working Time Directive in a large teaching hospital: a strategic approach.

This paper describes the strategy which achieved European Working Time Directive (EWTD) compliance at the Royal Free Hampstead NHS Trust in medicine and surgery. Compliance with EWTD regulations was assessed by diary card exercise, clinical care assessed through critical incident reports, electronic handover documents and nursing reports, training opportunities assessed by unit training directors, cost controls assessed by finance department analysis, and workload assessed by staff attendance on wards, in casualty and in theatres. There was a change in focus of care to a consultant-led, specialist registrar- (SpR-)driven service extending into evenings and on weekends, coupled with a move to a multi-skilled team for night cover, and to a move from traditional on-call shifts to a full shift system across both medicine and surgery. Compliance with the EWTD was achieved whilst maintaining good standards of clinical care, ensuring training opportunities for doctors in training, controlling payroll costs, removing the need for locums, and reducing workload for both junior doctors and consultants.