Guideline No. 445: Management of Chronic Pelvic Pain.

OBJECTIVE: To provide evidence-based recommendations for the management of chronic pelvic pain in females. TARGET POPULATION: This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain. BENEFITS, HARMS, AND COSTS: The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability. EVIDENCE: Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals. TWEETABLE ABSTRACT: Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments. SUMMARY STATEMENTS: RECOMMENDATIONS.

Maternal and child biomonitoring strategies and levels of exposure in western Canada during the past seventeen years: The Alberta Biomonitoring Program: 2005-2021.

The Alberta Biomonitoring Program (ABP) was created in 2005 with the initial goal of establishing baseline levels of exposure to environmental chemicals in specific populations in the province of Alberta, Canada, and was later expanded to include multiple phases. The first two phases focused on evaluating exposure in pregnant women (Phase One, 2005) and children (Phase Two, 2004-2006) by analyzing residual serum specimens. Phase Three (2013-2016) employed active recruitment techniques to evaluate environmental exposures using a revised list of chemicals in paired serum pools from pregnant women and umbilical cord blood. These three phases of the program monitored a total of 226 chemicals in 285 pooled serum samples representing 31,529 individuals. Phase Four (2017-2020) of the ABP has taken a more targeted approach, focusing on the impact of the federal legalization of cannabis on the exposure of pregnant women in Alberta to cannabis, as well as tobacco and alcohol using residual prenatal screening serum specimens. Chemicals monitored in the first three phases include herbicides, neutral pesticides, metals, metalloids, and micronutrients, methylmercury, organochlorine pesticides, organophosphate pesticides, parabens, phthalate metabolites, perfluoroalkyl substances (PFAS), phenols, phytoestrogens, polybrominated compounds, polychlorinated biphenyls (PCBs), dioxins and furans, polycyclic aromatic hydrocarbons (PAHs), and tobacco biomarkers. Phase Four monitored six biomarkers of tobacco, alcohol, and cannabis. All serum samples were pooled. Mean concentrations and 95% confidence intervals (CIs) were calculated for the chemicals detected in ≥25% of the sample pools. cross the first three phases, the data from the ABP has provided baseline exposure levels for the chemicals in pregnant women, children, and newborns across the province. Comparison within and among the phases has highlighted differences in exposure levels with age, geography, seasonality, sample type, and time. The strategies employed throughout the program phases have been demonstrated to provide effective models for population biomonitoring.

Contextualizing ovarian pain in the late 19th century-Part 1: Women with "hysteria" and "hystero-epilepsy".

"Hysteria" and "hystero-epilepsy" were common medical diagnoses among physicians during the nineteenth century. In Paris, L'Hôpital de la Salpêtrière-originally a hospice for the poor and a prison for prostitutes and other female inmates-became a center of great interest for the possible role of neurological diseases in these conditions. At the same time in the Americas and Europe, gynecologists were removing women's ovaries in cases with the same clinical conditions, which emphasized the role of the ovaries in contemporary hysteria studies in France, Great Britain, and the United States. The objective of this article is to explore nineteenth-century conceptualizations of ovarian pain as an organ-pathological substrate for a portion of these diagnoses. The theoretical role of the pelvic organs in these diagnoses has waxed and waned over the centuries, but there have not been many detailed explorations of the associated clinical phenomena. Suggesting an organic basis (le substratum organique) for the diagnoses remains a precarious notion, given the universally repudiated role of the uterus and decreasing interest in the ovary. In contemporary literature, the potential role of the ovary has not been addressed from a detailed medical perspective, however.

Contextualizing ovarian pain in the late 19th century - Part 2: Ovarian-based treatments of "hysteria".

The peculiar therapeutic practice of "ovarian compression"-paradoxically, both in initiating and in terminating hysterical activity-remains largely unexplained territory from both historical and medical perspectives. The gynecological indications of "hysteria" and "hystero-epilepsy" are now considered to be among similar questionable indications as contemporaneous "nymphomania" and "epilepsy." This article analyzes historical clinical observations, as well as surgical experiences of the time, to determine if there has been a uniform understanding of the ovarian contribution to "hystero-epilepsy." The respective findings are interpreted in light of the physiology of "chronic pelvic pain." Evidence for pain as a source of hystero-epileptic attacks is further represented through a series of clinical photographs suggesting a link to current problems, such as severe left-lower-quadrant pain. The emerging insights link more clearly to the functional role (le rôle fonctionnel) of the ovaries in relation to the "fits" of hystero-epileptic patients, while validating women's pain experiences during the latter part of the nineteenth century. Differences in the interpretation of disease concepts between Robert Battey (1828-1895) and Octave Terrillon (1844-1895) thereby permit an understanding of variations in the use of the removal of women's ovaries for pain.

Botulinum toxin injection for chronic pelvic pain: A systematic review.

INTRODUCTION: Botulinum toxin has proven therapeutic effects in alleviating pain in several myofascial disorders, with an expanding potential in chronic pelvic pain. The objective of this systematic review is to evaluate the efficacy and safety of botulinum toxin injection as an off-label treatment for female chronic pelvic pain. MATERIAL AND METHODS: Using PRISMA guidelines, MEDLINE, EBM Reviews, PubMed, CINAHL, TRIP Database, EMBASE, Web of Science and gray literature were searched. Studies assessing the efficacy of botulinum toxin for chronic pelvic pain in adult females, with 10 or more women, published in English up to 13 January 2020, were included. All eligible studies were reviewed and data were extracted by two independent reviewers using a standardized form. Quality of evidence was graded using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Ottawa-Newcastle scale for observational studies. RESULTS: In all, 491 records were screened. Seventeen articles were included in the final review: 5 randomized controlled trials and 12 observational studies. The quality of evidence ranged from low to high. There was a large degree of heterogeneity in study designs, and thus a meta-analysis was not feasible. All observational studies concluded that botulinum toxin was an effective treatment for chronic pelvic pain, with the greatest change in visual analog scale from 8.69 at baseline to 3.07 at 24 months post-injection. However, only one of the five randomized controlled trials found statistical significant differences favoring botulinum toxin in the reporting of the EQ-5D (botulinum 0.78 [0.69-1.00], control 0.69 [0.25-0.81], P = .03) and frequency of intercourse (botulinum 1 [1-1.75], placebo 1 [0-1], P = .025). The most common adverse effect was transient localized pain at injection site (6%-88%). No serious adverse events were reported. CONCLUSIONS: Although observational studies were encouraging, there is insufficient high quality evidence to recommend botulinum toxin injection for chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality in its treatment efficacy are indicated.

Analysis of growth and biofilm formation of bacterial pathogens on frequently used spinal implant materials.

STUDY DESIGN: A microscopy-based investigation of the permissive factors leading towards bacterial adherence on commonly utilized spinal implants. OBJECTIVE: The adherence and subsequent colonization and biofilm formation of bacteria on orthopaedic implants represents one of the most serious problems facing orthopaedic surgeons. Once a biofilm is formed, surgeons may have to resort to implant removal, a strategy that may cause substantial patient morbidity and lead to additional cost to the healthcare system. This problem has been further compounded by the rise of antibiotic-resistant strains of bacterial pathogens. In this study, two commonly encountered bacterial pathogens in surgical site infections (SSI) were characterized for adherence pattern, density, and propagation on five commonly used spinal implant materials via scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The results show that bacterial adherence is largely dependent on the microtopographical features observed on the surface of the materials tested. METHODS: Five commonly utilized spinal implant materials were inoculated with two of the most common nosocomial pathogens and visualized via scanning electron microscopy and confocal laser scanning microscopy. RESULTS: Analysis of 90 spinal implant pieces showed that even though no material showed the ability to prevent adherence of both pathogens tested, the presence of surface imperfections and rougher microtopography was found to harbor the most bacterial presence. CONCLUSION: Our data suggests that implants materials with uniform surface and minimal imperfections may reduce the ability of bacterial to adhere to implants. LEVEL OF EVIDENCE: Level I evidence: "Investigation of a diagnostic test".

Temporal Summation in Chronic Pelvic Pain.

OBJECTIVE: This study sought to characterize central sensitization further among women with chronic pelvic pain by identifying temporal summation using a cotton-tipped applicator test that can be used at the bedside. METHOD: A total of 36 women (18 with chronic pain and allodynia; 18 without pain) were recruited. Both groups were randomly assigned to receive 3 strokes of a benign stimulus on the abdomen at differing frequencies: 10, 30, or 100 seconds. Each group included 6 women. Pain was assessed using a rating scale of 1 to 10. Data were analyzed using the multivariate approach to repeated measures analysis of variance. RESULTS: The pattern of pain scores differed significantly between women with and without chronic pain (P = 0.002). Women with chronic pelvic pain and allodynia showed a statistically significant increase in pain with successive strokes of the cotton-tipped applicator (P = 0.012 for stroke 1 vs. 2, P = 0.026 for stroke 2 vs. 3, and P = 0.005 for stroke 1 vs. 3). CONCLUSION: Women with chronic pelvic pain and allodynia showed significant worsening of pain with successive strokes of a cotton-tipped applicator. This finding indicates that pain wind-up and central sensitization are present in women with chronic pelvic pain and allodynia. Identification of summation is further evidence of neuroplasticity, which is helpful in innovative therapies for chronic pelvic pain.

Commonly Encountered Skin Biome-Derived Pathogens after Orthopedic Surgery.

Background: Normal skin microbiota influence susceptibility to surgical infections. The distribution of skin bacteria differs by anatomic site, and given the right conditions, almost any of these bacteria can become an opportunistic pathogen. Methods: This paper provides a thorough review of the most commonly encountered bacteria in various regions of the body and their isolation from operative incisions at those locations. These data may be useful in optimizing targeted antibiotic therapy for surgical site infections and provide a better understanding of the skin biome distribution at specific surgical sites. Conclusion: Typical skin-borne flora, surgical site infections, orthopedic infections by body part, and drug-resistant pathogens are reviewed.

No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain.

OBJECTIVE: To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES: Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE: Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES: The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS: The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; G) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

No 164 - Directive clinique de consensus pour la prise en charge de la douleur pelvienne chronique.

OBJECTIF: Améliorer La compréhension de la douleur pelvienne chronique (DPC) et fournir des directives cliniques factuelles qui bénéficieront aux fournisseurs de soins de santé primaires, aux obstétriciens-gynécologues et aux spécialistes de la douleur chronique. FARDEAU DE LA SOUFFRANCE: La DPC est une pathologie débilitante courante qui affecte les femmes. Elle est à l'origine d'importantes souffrances personnelles et de dépenses de santé considérables associées aux interventions, dont de multiples consultations et un grand nombre de traitements médicaux et chirurgicaux. Puisque la pathophysiologie sous-jacente de cet état pathologique complexe est mal comprise, ces traitements n'ont obtenu que des taux de réussite variables. ISSUES: Efficacité des options diagnostiques et thérapeutiques (y compris l'évaluation du dysfonctionnement myofascial); soins multidisciplinaires; un modèle de réadaptation mettant l'accent sur l'obtention d'un fonctionnement supérieur malgré la présence d'une certaine douleur (plutôt que de chercher à obtenir une guérison totale); et utilisation appropriée des opiacés pour le soulagement de la douleur chronique. PREUVES: Des recherches ont été menées dans Medline et la base de données Cochrane en vue d'en tirer les articles de langue anglaise, publiés entre 1982 et 2004, portant sur des sujets liés à la DPC, dont la gestion des soins actifs, le dysfonctionnement myofascial et les options thérapeutiques médicales et chirurgicales. Les membres du comité ont analysé la littérature pertinente, ainsi que les données disponibles tirées d'une évaluation des besoins des personnes présentant une DPC; ils ont fait appel à une approche de consensus pour l'élaboration des recommandations. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur l'examen médical périodique. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport (Tableau 1). RECOMMANDATIONS: Les recommandations visent ce qui suit : (a) compréhension des besoins des femmes présentant une DPC ; (b) évaluation clinique générale ; (c) évaluation pratique des niveaux de douleur ; (d) douleur myofasciale ; (e) médicaments et interventions chirurgicales ; (f) principes de la gestion des opiacés; (g) utilisation accrue de l'imagerie par résonance magnétique (IRM) ; (h) documentation de l'étendue de La maladie constatée au moyen de la chirurgie ; (i) thérapies non conventionnelles; (j) accès à des modèles de soins multidisciplinaires faisant appel à des composantes de physiothérapie (comme l'exercice et la posture) et de psychologie (comme La thérapie cognitivo- comportementale), conjointement avec d'autres disciplines médicales, telles que La gynécologie et l'anesthésie ; (k) attention accrue portée à La DPC dans La formation des professionnels de La sante ; et (l) attention accrue portée à la DPC dans le domaine des recherches officielles et de haut calibre. Le comité recommande que les ministères provinciaux de La Sante prennent des mesures en faveur de la création d'équipes multidisciplinaires pouvant assurer La prise en charge de cette pathologie. Chapitre 2 : Portee et definition de La douleur pelvienne chronique Chapitre 3 : Anamnese, examen physique et évaluation psychologique Chapitre 4 : Explorations Chapitre 5 : Sources de douleur pelvienne chronique Chapitre 6 : Causes urologiques et gastro-intestinales de La douleur pelvienne chronique Chapitre 7 : Dysfonctionnement myofasclal Chapitre 8 : Therapie medicale - résultats en matiere d'efficacite Chapitre 9 : Chirurgie - résultats en matiere d'efficacite Chapitre 11 : Prise en charge multidisciplinaire de La douleur chronique Chapitre 14 : Orientations futures.

Pain, psychosocial tests, pain sensitization and laparoscopic pelvic surgery.

BACKGROUND AND AIMS: Individuals with non-acute pain are challenged with variable pain responses following surgery as well as psychological challenges, particularly depression and catastrophizing. The purpose of this study was to compare pre- and postoperative psychosocial tests and the associated presence of sensitization on a cohort of women undergoing elective laparoscopic surgery for non-acute pain defined as pain sufficient for surgical investigation without persistent of chronic pain. METHODS: The study was a secondary analysis of a previous report (Am J Obstet Gynecol 2014 Oct;211(4):360-8.). The study was a prospective cohort trial of 77 women; 61 with non-acute pain and 16 women for a tubal ligation. The women had the following tests: Pain Disability Index, Pain Catastrophizing Scale, CES-D (Center for Epidemiologic Studies Depression Scale) depression scale and the McGill Pain Scale (short form) as well as their average pain score and the presence of pain sensitization. All test scores were correlated together and comparisons were done using paired t-test. RESULTS: There were reductions in pain and psychosocial test scores that were significantly correlated. Pre-operative sensitization indicated greater changes in psychosocial tests. CONCLUSIONS: There was a close association of tests of psychosocial status with average pain among women having surgery on visceral tissues. Incorporation of these tests in the pre- and postoperative evaluation of women having laparoscopic surgery appears to provide a means to a broader understanding of the woman's pain experience.

The significance and evolution of menstruation.

Historically, the evolutionary origins of menstruation have been based on two theories: the ability to eliminate infectious agents carried to the uterus with spermatozoa and the comparative conservation of energy with menstruation compared to its absence. In the menstruating species, more recent theories have identified spontaneous decidualization as the key adaptive mechanism. Spontaneous decidualization is seen as a mechanism to provide the mother with protection from the invasive characteristics of the embryo. Physiologically, menstruation involves complex interactions of inflammation and vascular mechanisms to stabilize the endometrium and allow a regulated loss of endometrial tissues and blood. A variety of human illnesses can be better understood as vulnerabilities associated with these evolutionary developments, including recurrent pregnancy loss, placenta accreta, ectopic pregnancy, endometriosis, adenomyosis, dysmenorrhea, and chronic pelvic pain. While the evolutionary aspects of these diseases indicate why such illnesses can occur, in some instances, they also provide a basis for treatment, prevention and future research direction.

Identification of a putative man-made object from an underwater crash site using CAD model superimposition.

In order to identify an object in video, a comparison with an exemplar object is typically needed. In this paper, we discuss the methodology used to identify an object detected in underwater video that was recorded during an investigation into Amelia Earhart's purported crash site. A computer aided design (CAD) model of the suspected aircraft component was created based on measurements made from orthogonally rectified images of a reference aircraft, and validated against historical photographs of the subject aircraft prior to the crash. The CAD model was then superimposed on the underwater video, and specific features on the object were geometrically compared between the CAD model and the video. This geometrical comparison was used to assess the goodness of fit between the purported object and the object identified in the underwater video.

Protocol for a placebo-controlled, within-participants crossover trial evaluating the efficacy of intranasal oxytocin to improve pain and function among women with chronic pelvic musculoskeletal pain.

INTRODUCTION: This protocol presents the rationale and design for a trial evaluating the efficacy of intranasal oxytocin in improving pain and function among women with chronic pelvic musculoskeletal pain. Oxytocin is a neuropeptide traditionally recognised for involvement in labour, delivery and lactation. Novel evidence suggests that oxytocin decreases pain sensitivity in humans. While oxytocin administration has been reported to lower pain sensitivity among patients experiencing chronic back pain, headache, constipation and colon pain, no research has evaluated the association between intranasal oxytocin and chronic pelvic musculoskeletal pain. The association between oxytocin and pain may differ in women with chronic pelvic musculoskeletal pain relative to other chronic pain conditions because of the abundance of oxytocin receptors in the uterus. METHODS AND ANALYSIS: This is a prospective, randomised, placebo-controlled, double-blind, within-participants crossover trial. 50 women with chronic pelvic musculoskeletal pain will be recruited through a local chronic pain centre and gynaecology clinics. Women will complete baseline measures and be randomised to an experimental or control condition that involve 2 weeks of self-administering twice-daily doses of 24 IU intranasal oxytocin or placebo, respectively. Women will then undergo a 2-week washout period before crossing over to receive the condition that they had not yet received. The primary outcome will be pain and function measured using the Brief Pain Inventory-Short Form. Secondary outcomes include emotional function, sleep disturbance and global impression of change. This trial will provide data on the 14-day safety and side-effect profile of intranasal oxytocin self-administered as an adjuvant treatment for chronic pelvic musculoskeletal pain. ETHICS AND DISSEMINATION: This trial was granted approval from Health Canada and the University of Calgary Conjoint Health Research Ethics Board, and is registered online at ClinicalTrials.gov (#NCT02888574). Results will be disseminated to healthcare professionals through peer-reviewed publications and to the general public through press releases. TRIAL REGISTRATION NUMBER: NCT02888574; Pre-results.

Evolutionary considerations in the development of chronic pelvic pain.

Chronic pelvic pain is common among women of reproductive age and is associated with significant morbidity and comorbidities. In this Viewpoint, we explore the evolutionary cause of pelvic pain and summarize evidence that supports a menstruation-related evolutionary cause of chronic visceral pelvic pain: (1) lifetime menstruation has increased; (2) severe dysmenorrhea is common in the chronic pelvic pain population, particularly among those with pain sensitization; and (3) a potential biological mechanism can be identified. Thus, chronic pelvic pain may arise from the mismatch between the slow pace of biological evolution in our bodies and the relatively rapid pace of cultural changes that have resulted in increased menstrual frequency due to earlier menarche, later mortality, and lower fecundity. One possible mechanism that explains the development of persistent pain from repeated episodes of intermittent pain is hyperalgesic priming, a physiological process defined as a long-lasting latent hyperresponsiveness of nociceptors to inflammatory mediators after an inflammatory or neuropathic insult. The repetitive severely painful menstrual episodes may play such a role. From an evolutionary perspective the relatively rapid increase in lifetime menstruation experience in contemporary society may contribute to a mismatch between lifetime menstruation and the physiological pain processes, leading to a maladaptive state of chronic visceral pelvic pain. Our current physiology does not conform to current human needs.

Allodynia and Dysmenorrhea.

OBJECTIVE: Cutaneous allodynia (pain from a non-painful stimulus) is a sign that can be observed among women with chronic pelvic pain. Dysmenorrhea is recognized as a common cause of chronic pelvic pain in women. This study was conducted to explore the frequency of allodynia and the relationship between allodynia and severe dysmenorrhea. METHODS: We enrolled women in this study if they had experienced chronic pelvic pain for more than six months. Women provided information regarding their chronic pelvic pain and menstrual function, specifically the severity of their menstrual pain. In addition to a gynaecological assessment, women were tested for allodynia and pain pressure thresholds. RESULTS: Abdominal allodynia was present in 62.1% of 181 women who participated. Women with allodynia had a significantly greater rate of severe dysmenorrhea and significantly greater duration of severe dysmenorrhea. Pain pressure thresholds were demonstrated to decrease significantly in relation to increasing duration of severe dysmenorrhea. CONCLUSION: There is a greater frequency of chronic pain among women with a history of severe dysmenorrhea. Women who experienced prolonged severe dysmenorrhea were shown to have a progressive increase in pain sensitivity (reflected in reduced pain pressure thresholds). These findings support efforts to manage dysmenorrhea early in a woman's life with approaches to suppress menstrual function.

Autologous Fat Grafting to the Breast Using REVOLVE System to Reduce Clinical Costs.

BACKGROUND: With the increasing popularity of fat grafting over the past decade, the techniques for harvest, processing and preparation, and transfer of the fat cells have evolved to improve efficiency and consistency. The REVOLVE System is a fat processing device used in autologous fat grafting which eliminates much of the specialized equipment as well as the labor intensive and time consuming efforts of the original Coleman technique of fat processing. This retrospective study evaluates the economics of fat grafting, comparing traditional Coleman processing to the REVOLVE System. METHODS: From June 2013 through December 2013, 88 fat grafting cases by a single-surgeon were reviewed. Timed procedures using either the REVOLVE System or Coleman technique were extracted from the group. Data including fat grafting procedure time, harvested volume, harvest and recipient sites, and concurrent procedures were gathered. Cost and utilization assessments were performed comparing the economics between the groups using standard values of operating room costs provided by the study hospital. RESULTS: Thirty-seven patients with timed procedures were identified, 13 of which were Coleman technique patients and twenty-four (24) were REVOLVE System patients. The average rate of fat transfer was 1.77 mL/minute for the Coleman technique and 4.69 mL/minute for the REVOLVE System, which was a statistically significant difference (P < 0.0001) between the 2 groups. Cost analysis comparing the REVOLVE System and Coleman techniques demonstrates a dramatic divergence in the price per mL of transferred fat at 75 mL when using the previously calculated rates for each group. CONCLUSIONS: This single surgeon's experience with the REVOLVE System for fat processing establishes economic support for its use in specific high-volume fat grafting cases. Cost analysis comparing the REVOLVE System and Coleman techniques suggests that in cases of planned fat transfer of 75 mL or more, using the REVOLVE System for fat processing is more economically beneficial. This study may serve as a guide to plastic surgeons in deciding which cases might be appropriate for the use of the REVOLVE System and is the first report comparing economics of fat grafting with the traditional Coleman technique and the REVOLVE System.

The Significance of Cutaneous Allodynia in a Woman With Chronic Pelvic Pain.

BACKGROUND: This is a case report of sensory assessment in a woman with severe chronic pelvic pain following uterine artery embolization, and a discussion of a commonly observed sensory manifestation (allodynia) associated with chronic pelvic pain due to gynaecological conditions. Allodynia, as a common sensory abnormality can be readily detected at the bedside and represents the development of pain sensitization. Emergence of abdominal and perineal allodynia (assessed by cotton swap stroking and/or questionnaire) is associated with the development of the clinical features of sensitization: continuous pelvic pain, muscle tenderness, and reduced pressure pain thresholds. CASE: A uterine artery embolization was performed on a 42-year-old woman to treat a postpartum hemorrhage. The woman experienced severe pain immediately following the procedure, and it had persisted for one year when she was referred for chronic unrelenting pain. She was found to have extensive allodynia, myofascial dysfunction, and reduced pain thresholds. A hysterectomy was undertaken. As the pain persisted, botulinum toxin was administered to the lower abdomen in the region of reduced pain thresholds. Partial resolution of pain, physical limitation, and allodynia resolved one year after the hysterectomy and shortly after the injections of four tender regions of the anterior cutaneous nerves with 2.5 and 5.0 IU of botulinum toxin. CONCLUSION: Testing for allodynia is a validated bedside test for pain sensitization. A clinical trial of botulinum toxin is indicated for the management of chronic pelvic pain associated with allodynia and pain sensitization.

Contexte : Cet exposé de cas présente une évaluation sensorielle menée chez une femme qui a connu de graves douleurs pelviennes chroniques à la suite d'une embolisation des artères utérines et traite d'une manifestation sensorielle courante (allodynie) qui est associée à des douleurs pelviennes chroniques attribuables à des troubles gynécologiques. L'allodynie (en tant qu'anomalie sensorielle courante) peut facilement être détectée au chevet de la patiente et représente le développement d'une sensibilisation douloureuse. L'apparition d'une allodynie abdominale et périnéale (déterminée par effleurement au moyen d'un écouvillon et/ou par l'administration d'un questionnaire) est associée à celle des caractéristiques cliniques de la sensibilisation : douleur pelvienne continuelle, endolorissement musculaire et baisse des seuils de la douleur provoquée par une pression. Cas : Une embolisation des artères utérines a été menée chez une femme de 42 ans pour la prise en charge d'une hémorragie postpartum. La patiente a connu de graves douleurs immédiatement à la suite de l'intervention; après une année de douleurs persistantes, elle a été orientée vers des services de prise en charge de la douleur chronique tenace. La présence d'une allodynie étendue, d'une dysfonction myofasciale et d'une baisse des seuils de la douleur a été constatée. Une hystérectomie a été menée. Puisque la douleur persistait, de la toxine botulinique a été administrée dans la partie inférieure de l'abdomen, en ciblant la région connaissant une baisse des seuils de la douleur. La résolution partielle de la douleur, les limites physiques et l'allodynie se sont résorbées un an à la suite de l'hystérectomie et peu après les injections de 2,5 et de 5,0 UI de toxine botulinique dans les quatre régions douloureuses des nerfs cutanés antérieurs. Conclusion : Le dépistage de l'allodynie constitue un test dont la tenue au chevet a été validée pour ce qui est de la sensibilisation douloureuse. La tenue d'un essai clinique portant sur l'utilisation de toxine botulinique pour la prise en charge de la douleur pelvienne chronique qui est associée à l'allodynie et à la sensibilisation douloureuse s'avère indiquée.