Skeletal muscle relaxants for the treatment of myofascial pelvic pain and high tone pelvic floor disorders.

PURPOSE OF REVIEW: Chronic pelvic main is a complex process that includes many causes. In gynecology, the treatment of myofascial pelvic pain and high tone pelvic floor disorders can be managed with skeletal muscle relaxants for select clinical indications. A review of skeletal muscle relaxants will be included for gynecologic indications. RECENT FINDINGS: There are limited studies on vaginal skeletal muscle relaxants, but there can be oral forms used for chronic myofascial pelvic pain. They function as antispastic, antispasmodic, and combination of the two modes of action. Diazepam is the most studied for myofascial pelvic pain in both oral and vaginal formulations. Its use can be combined with multimodal management to optimize outcomes. Other medications have limitations due to dependency and limited studies that demonstrate improvement in pain scales. SUMMARY: Skeletal muscle relaxants have limited high quality studies for chronic myofascial pelvic pain. Their use can be combined with multimodal options to improve clinical outcomes. Additional studies are needed for vaginal preparations and evaluation of safety and clinical efficacy for patient reported outcomes measures in patients living with chronic myofascial pelvic pain.

The Effect of a Global Surgery Resident Rotation on Physician Practices Following Residency: The Mount Sinai Experience.

OBJECTIVE: The goal of the study was to evaluate the impact of Mount Sinai's international rotation on physician practices and attitudes following residency. DESIGN: An anonymous, retrospective study was conducted using an email survey. The initial survey was sent out in July 2015 with a second opportunity in September 2015. SETTING: Mount Sinai Hospital, New York City. PARTICIPANTS: All 62 graduates of the Mount Sinai General and Plastic Surgery residencies who participated in the international rotation over the last 10 years. RESULTS: The primary outcome was level of involvement in service medicine with a secondary outcome examining participants views on the value of international rotations during residency. The response rate for the survey was 71% (44/62). Since leaving residency, 53% have been involved in one or more types of service medicine, 59% have been involved in at least one experience practicing medicine in an underserved area and 45% state that their current practice incorporates global surgery or service. 61% report that the rotation encouraged an interest in practicing in an underserved area and 44% (8/18) of those with no prior interest in global health reported that the rotation encouraged an interest. Respondents generally believe global health work could be rewarding (89%), provide opportunity for professional development (77%), and that residency should include global health electives (93%). CONCLUSIONS: Our results suggest that a mandatory global health rotation may encourage an interest in service medicine. Thus, program directors should continue to provide and encourage participation in international rotations during surgical residency.

Deep Brain Stimulation for Status Dystonicus: A Case Series and Review of the Literature.

BACKGROUND: Status dystonicus (SD) is a rare and potentially life-threatening complication of primary or secondary dystonia, characterized by acute worsening of dystonic movements. There is no consensus regarding optimal treatment, which may be medical and/or surgical. METHODS: We present our experience with pallidal deep brain stimulation (DBS) in 5 DYT1-positive patients with SD and provide a review of the literature to examine optimal management. RESULTS: Of the 5 patients treated with pallidal DBS, all experienced postoperative resolution of their dystonic crisis within a range of 1-21 days. Long-term follow-up resulted in 1 patient returning to preoperative baseline, 3 patients improving from baseline, and 1 patient making a complete recovery. Of the 28 SD patients (including our 5 patients) reported in the literature who were treated with DBS or ablative surgery, 26 experienced cessation of their dystonic crisis with a return to baseline function and, in most cases, clinical improvement. CONCLUSION: DBS is an effective therapeutic modality for the treatment of SD. In addition to the long-term benefits of stimulation, early and aggressive treatment may improve the overall outcome.

The Prognostic Significance of Lymph Node Ratio in Carcinoid Tumors.

OBJECTIVES: Nodal metastases are an important prognostic factor in survival for patients with carcinoid tumors. However, it is unclear if the current American Joint Committee on Cancer's gastrointestinal carcinoid staging guidelines, which look only at presence or absence of regional metastases (N1/N0), are fully utilizing lymph node data. Some research has indicated that lymph node ratios (LNRs) are powerful predictors of survival. In our study, we evaluated LNR in carcinoid tumors. METHODS: Eleven thousand one hundred eighty-nine carcinoid tumors recorded in the Surveillance, Epidemiology, and End Results database between 1988 and 2011 were evaluated. Receiver operating characteristic curves and the area under the receiver operating characteristic curve (AUC) were used to evaluate the ability of nodal involvement or LNR to predict 10-year survival. All analyses were performed using STATA and SAS version 9.3. RESULTS: Receiver operating characteristic curve analysis indicated that LNR and node positivity were both predictive of 10-year survival, AUC = 0.734, P < 0.0001; AUC = 0.7048, P < 0.0001. Lymph node ratio was 88% specific and 50% sensitive in predicting 10-year survival. N1 was 88% specific and 49% sensitive in predicting 10-year survival. CONCLUSIONS: Our study indicated that LNR is an independent predictor of survival for patients with carcinoid tumors but was no better than N1/N0 for 10-year survival.