Consent Practices for Assisted Vaginal Births (AVB) at Two Tertiary Care Hospitals: A Retrospective Review of Physician Documentation.

OBJECTIVE: To determine whether assisted vaginal birth (AVB) consent documentation, a surrogate for in vivo consent, aligns with Canadian practice guidelines at 2 Canadian tertiary-level obstetric centres. METHODS: This was a retrospective review of AVBs (vacuum and forceps) from July 2019 to December 2019 at 2 tertiary-level hospitals with template-based (Site 1) or dictation-based (Site 2) documentation. We extracted, from obstetric and neonatal charts, AVB type, physician and documenter types (resident/fellow/family doctor/generalist obstetrics and gynecology [OBGYN]/maternal-fetal medicine), and consent elements (present/absent) based on a predetermined checklist. Data were summarized and comparisons were made using chi-square test, Fisher exact test, and logistic regression, where appropriate. RESULTS: We identified 551 AVBs (156 forceps, 395 vacuum) with most documentation completed by generalist OBGYNs or residents (333/551, 60.5%). Most vacuum-assisted deliveries documented no specific maternal (366/395, 92.7%) or neonatal (364/395, 92.2%) risks, and 107/156 (68.6%) and 106/156 (67.9%) forceps-assisted deliveries lacked specific documentation of maternal and neonatal risk, respectively. At Site 2, postpartum hemorrhage risk at vacuum-assisted deliveries was more commonly documented (6/90 [6.7%] vs. 2/395 [0.7%], P = 0.002) as was at least 1 neonatal risk and risk of obstetrical anal sphincter injury at forceps-assisted deliveries (50/133 [37.6%] vs. 0/23 [0%], P < 0.001) and (43/133 [32.3%] vs. 0/23 [0%], P = 0.001), respectively. CONCLUSIONS: Opportunity to improve AVB consent documentation exists, warranting quality improvement initiatives.

The Quality and Quantity of Lower Genital Tract Research Across Multiple Journals.

OBJECTIVE: This study aimed to determine the quantity and quality of lower genital tract disease (LGTD) research by topic published across a variety of gynecology and dermatology journals. METHODS: Authors accessed all articles that were rejected (1,111, 59.5%) and accepted (755, 40.5%) by the Journal of Lower Genital Tract Disease ( JLGTD ) from 2008 to 2020. Studies were categorized by key topic: Cervix, Human Papillomavirus, Vulva, Vagina, Anal, and Other. Studies were further subcategorized based on methodology. These data were compared with all LGTD publications from 2018 to 2020 in 4 other widely recognized journals ( Obstetrics and Gynecology , The British Journal of Obstetrics and Gynaecology , JAMA Dermatology , and the British Journal of Dermatology ). RESULTS: Most JLGTD -accepted submissions were related to the cervix (298/755, 39.5%) and vulva (189/755, 25.0%). Rates of acceptance were similar across all key topic areas. Only 3.2% of publications in the other 4 journals (92/2,932) were related to LGTD topics. Across all 5 journals, vulva studies were most commonly case reports/case series (82/218, 37.6%), with a low prevalence of systematic reviews/meta-analyses (4/218 1.8%). In comparison, cervix studies had the highest number of systematic reviews/meta-analyses (14/317, 4.4%) and the lowest number of case reports (14/317, 4.4%). CONCLUSIONS: Vulvar research is of lower quality compared with cervix research published across 5 journals. Comparing accepted versus rejected articles in JLGTD , there is no publication bias against vulva topics noted; rather, the overall research quality in vulva is lower than that of cervical disease. This is a call to action for higher quality vulvar research.

Vulvar Lichen Sclerosus: Outcomes Important to Patients in Assessing Disease Severity.

OBJECTIVE: The aim of the study was to determine outcome measures that women with vulvar lichen sclerosus (LS) rate as important in assessing disease severity with the ultimate goal of including these items in a disease severity rating tool. METHODS: An online survey of women older than 18 years with a diagnosis of vulvar LS was performed. The survey was posted in Facebook LS support groups. Participants rated items on a scale from 1 to 5 (not important to include to essential to include) in a disease severity scale. Participants also rated how often they were affected by various symptoms on a scale from 1 to 5 (never to daily). Mean rating of importance and mean rating of frequency for each sign and symptom were calculated. T tests were used to compare patients with biopsy-proven disease with those with a clinical diagnosis of LS. RESULTS: Nine hundred fifty-eight participants completed the survey (86% completion rate). Patients felt that the most important items to assess disease severity were irritation (4.39), fusion of the labia (4.38), soreness (4.37), itch (4.34), change in vulvar skin (4.34), and decrease in quality of life (4.33). The most frequently experienced items by those with LS were irritation (3.92), changes in appearance of vulvar skin (3.92), and discomfort (3.89). There were no differences between patients with biopsy-proven LS versus those diagnosed on clinical examination. CONCLUSIONS: Future LS severity assessment tools will need to include a combination of patient-rated symptoms, clinical rated signs and anatomical changes, and quality of life measures.

Adult Vulvar Lichen Sclerosus: Can Experts Agree on the Assessment of Disease Severity?

OBJECTIVE: The objective of this study was to test the severity rating of the signs and architectural changes for interrater reliability among world experts via analysis of lichen sclerosus (LS) photographs. METHODS: A recent Delphi consensus exercise established a list of symptoms, signs, and architectural changes, which experts feel are important to include in a severity scale. Photographs of vulvar LS were manually extracted from patient charts and 50 photographs with a range of severity of signs and architectural changes were chosen. Lichen sclerosus experts were invited to take part in the study and 3 dermatologists and 3 gynecologists were selected for their expertise and geographic variety. Raters assessed the photographs for multiple signs and architectural changes as well as an overall impression of disease severity on a 4-point Likert scale. Intraclass correlation coefficients were calculated. RESULTS: The intraclass correlation coefficients were very poor for individual signs and architectural changes as well as for overall disease severity when analyzed for all 6 raters as well as when analyzed with dermatologists' and gynecologists' responses grouped separately. There were no statistically significant correlations found. CONCLUSIONS: Global experts were unable to agree on any signs, architectural changes, or an overall global impression to assess vulvar LS disease severity based on analysis of vulvar photographs. Standardized descriptions regarding what constitutes mild, moderate, and severe signs and anatomical changes are required before further scale development can occur.

Development of the Adult Vulvar Lichen Sclerosus Severity Scale-A Delphi Consensus Exercise for Item Generation.

OBJECTIVE: To generate a list of items through international expert consensus consisting of both symptoms and clinical signs for inclusion in an adult vulvar lichen sclerosus severity scale. METHODS: This study was carried out as a three-stage Delphi consensus exercise. After an extensive literature review, any items used to determine disease severity in previous clinical trials were compiled into a survey. The Delphi participants were recruited from the International Society for the Study of Vulvovaginal Disease most of whom were gynecologists and in practice for more than 20 years. Participants were asked to rate the importance of these items. Consensus was defined as 75% agreeing that an item was very important or essential toward determining disease severity. Participants were also asked to indicate preferred method of measurement for these items. RESULTS: Of approximately 400 members of the International Society for the Study of Vulvovaginal Disease, 66 participated in the study. Of the 14 symptoms presented, 7 reached consensus for inclusion. Of the 23 signs presented, 11 reached consensus for inclusion and 1 reached consensus for exclusion. Of the six architectural changes presented, all six reached consensus for inclusion. No consensus was reached regarding method of measurement for any of the symptoms and signs that reached consensus for inclusion. CONCLUSION: International consensus was reached for a variety of items for use in an adult vulvar lichen sclerosus severity scale that will be further developed and tested. Ideally, this scale will be used in clinical practice and in research to allow for high-quality trials.

Patients' Knowledge of Prenatal Screening for Trisomy 21.

This study's objective was to assess the knowledge of prenatal screening for Trisomy 21 in pregnant women in one institution in Canada. A cross-sectional survey measuring demographics, knowledge of screening, and health literacy, was administered to pregnant women. Of the 135 women who completed the survey, 74% had adequate knowledge of Trisomy 21 and associated screening procedures. Twenty-eight point one percent of women did not receive any counseling. Overall, 29.5% of women did not know that the screening test was optional and 10.2% of women underwent screening prior to having been counseled. Multigravidity (p < 0.05) and prior counseling (p < 0.001) were positively correlated with knowledge while first language other than English (p < 0.001) was negatively correlated with knowledge. Given these findings, an effort needs to be made on the part of health care providers to increase counseling rates to 100%, stressing the optional nature of the test to attain true informed consent.

Ignorance is bliss: women's knowledge regarding age-related pregnancy risks.

Pregnancy risks rise with age and the average age of first time mothers is rising. This study aimed to assess women's actual knowledge and their perceived knowledge of pregnancy complications relating to advanced maternal age. A cross-sectional survey was administered to primiparous women measuring demographics, knowledge of age-related pregnancy risks, previous counselling and health literacy. Of the 218 women surveyed, the mean knowledge score was not significantly different for women <35 years of age compared to women ≥35 years of age (p = .09). Although there was no difference in knowledge between the two groups, women ≥35 years of age perceived themselves to be more knowledgeable than those under 35 (p < .01). The majority of women (67%) wanted further counselling on this topic and indicated a preference for their doctor to counsel them (76%). Women require counselling informing them of their increased risk of complications if they begin childbearing at older ages. Impact statement What is already known on this subject: The average age of first time mothers is rising worldwide. Pregnancy risks rise with age, especially in first time mothers. Previous studies have shown that knowledge of age-related pregnancy risks correlate with educational level and health literacy. What the results of this study add: This study supports those findings and also demonstrates that perceived knowledge does not correlate with measured knowledge of age-related pregnancy risks. Women ≥35 years of age (higher-risk women) are no more knowledgeable than their younger counterparts though they perceive themselves to be better informed. Greater education regarding these risks may allow women to mitigate some of these risks through lifestyle and diet alteration and will prepare women for what to expect if these risks and complications occur. The majority of women in this study seek pregnancy information on the internet, but desire further counselling from their doctors regarding age-related pregnancy risks. What the implications are of these findings for clinical practice and/or further research: Given these results, physicians must consider making greater efforts to counsel women about pregnancy risks in advanced maternal age and tailor these conversations to suit the educational level and health literacy of each individual patient.

Progerin-Induced Replication Stress Facilitates Premature Senescence in Hutchinson-Gilford Progeria Syndrome.

Hutchinson-Gilford progeria syndrome (HGPS) is caused by a mutation in LMNA that produces an aberrant lamin A protein, progerin. The accumulation of progerin in HGPS cells leads to an aberrant nuclear morphology, genetic instability, and p53-dependent premature senescence. How p53 is activated in response to progerin production is unknown. Here we show that young cycling HGPS fibroblasts exhibit chronic DNA damage, primarily in S phase, as well as delayed replication fork progression. We demonstrate that progerin binds to PCNA, altering its distribution away from replicating DNA in HGPS cells, leading to γH2AX formation, ATR activation, and RPA Ser33 phosphorylation. Unlike normal human cells that can be immortalized by enforced expression of telomerase alone, immortalization of HGPS cells requires telomerase expression and p53 repression. In addition, we show that the DNA damage response in HGPS cells does not originate from eroded telomeres. Together, these results establish that progerin interferes with the coordination of essential DNA replication factors, causing replication stress, and is the primary signal for p53 activation leading to premature senescence in HGPS. Furthermore, this damage response is shown to be independent of progerin farnesylation, implying that unprocessed lamin A alone causes replication stress.

E-Mail Communication Practices and Preferences Among Patients and Providers in a Large Comprehensive Cancer Center.

PURPOSE: Little is known about how electronic mail (e-mail) is currently used in oncology practice to facilitate patient care. The objective of our study was to understand the current e-mail practices and preferences of patients and physicians in a large comprehensive cancer center. METHODS: Separate cross-sectional surveys were administered to patients and physicians (staff physicians and clinical fellows) at the Princess Margaret Cancer Centre. Logistic regression was used to identify factors associated with current e-mail use. Record review was performed to assess the impact of e-mail communication on care. RESULTS: The survey was completed by 833 patients. E-mail contact with a member of the health care team was reported by 41% of respondents. The team members contacted included administrative assistants (52%), nurses (45%), specialist physicians (36%), and family physicians (18%). Patient factors associated with a higher likelihood of e-mail contact with the health care team included younger age, higher education, higher income, enrollment in a clinical trial, and receipt of multiple treatments. Eighty percent of physicians (n = 63 of 79) reported previous contact with a patient via e-mail. Physician factors associated with a greater likelihood of e-mail contact with patients included older age, more senior clinical position, and higher patient volume. Nine hundred sixty-two patient records were reviewed, with e-mail correspondence documented in only 9% of cases. CONCLUSION: E-mail is commonly used for patient care but is poorly documented. The use of e-mail in this setting can be developed with appropriate guidance; however, there may be concerns about widening the gap between certain groups of patients.

Angiosarcoma of the Vulva: A Case Report.

This case illustrates that a very benign looking lesion can be an aggressive cancer. Vulvar lesions need a biopsy to rule out malignancy if they are painful, progressing in size, or changing in appearance.