Does enhanced "bundling" criteria improve outcomes? A comparative study of elective inductions.

OBJECTIVE: To assess outcomes and costs of dyads achieving elective induction bundle criteria with a favorable Bishop score. STUDY DESIGN: In a historical automated records-based cohort study, 180 dyads undergoing elective induction bundling at a single institution from 2009 to 2010 were compared to a pre-introduction of bundling cohort. The bundled cohort was then compared by Bishop score. RESULTS: The bundled cohort (n = 180) had a lower cesarean delivery rate (12% vs. 21%, p = 0.01), but neonatal special or intensive care admissions were not statistically significant compared to the pre-introduction of bundling cohort (n = 473). Ninety-six percent (n = 173) of the bundled cohort achieved bundle criteria. Those with a Bishop score > 6 (52%, n = 90) had fewer cesarean deliveries (4% vs. 19%, p = 0.003), fewer neonatal special or intensive care admissions (1% vs. 10%, p = 0.015), shorter induction time to vaginal delivery (8.8 vs. 17 hrs, p < 0.001), fewer cesareans for dystocia (75% vs. 94%, p = 0.002) or fetal heart rate abnormalities (25% vs. 50%, p = 0.015), and had one-sixth the average net income lost ($423 vs. $2,600, p < 0.001) compared to bundle achievers with a Bishop score of < or = 6. CONCLUSION: The elective induction bundle does not guarantee quality and should require favorable cervix instead of documented Bishop score to proceed with induction.

Application of Patient-Reported Outcomes Measurement Information System to chronic pelvic pain.

STUDY OBJECTIVES: To apply the Patient-Reported Outcomes Measurement Information System (PROMIS) recently developed by the National Institutes of Health in patients with chronic pelvic pain. Secondary objectives included evaluation of individual pain categories and of the effect of the occurrence of myofascial abdominal wall and pelvic floor muscle pain. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Chronic pelvic pain multidisciplinary referral center. PATIENTS: A total of 149 consecutive patients with chronic pelvic pain provided evaluable results. INTERVENTIONS: As part of a comprehensive evaluation, patients were assigned diagnoses based on standard criteria, and completed the 96-item short-form PROMIS. MEASUREMENTS AND MAIN RESULTS: Pain-related and global PROMIS scores were significantly worse than in the reference population (p <.05). The presence of myofascial pain was also associated with worse PROMIS scores. CONCLUSION: Chronic pelvic pain is associated with impaired quality of life regardless of the diagnosis, including myofascial pain.

Frequency and distribution of multiple diagnoses in chronic pelvic pain related to previous abuse or drug-seeking behavior.

BACKGROUND: The objective of this study was to describe the nature and number of pain diagnoses in a chronic pelvic pain population, and to determine the relationship between these and a patient's history of abuse, drug-seeking behavior, or initial symptom scores. METHODS: 175 consecutive patients were evaluated at the Summa Chronic Pelvic Pain Center and assigned diagnoses. These diagnoses included gynecologic pain, interstitial cystitis (IC), irritable bowel syndrome (IBS), pelvic floor tension myalgia, abdominal wall myalgia, and vulvodynia. The diagnosis of drug seeking was based upon a patient's refusal of non-narcotic management. RESULTS: Multiple diagnoses were common, occurring in 58% of all patients, and in up to 96% of those diagnosed with non-gynecologic pain. A history of abuse was present in 55% of all patients. Drug seeking was diagnosed in 13% of all patients. Significantly elevated IC, IBS, and myalgia scores were associated with previous abuse and multiple pain diagnoses. CONCLUSION: Patients with chronic pelvic pain frequently have multiple pain diagnoses, and non-gynecologic pain in particular is common. Multiple pain diagnoses and a history of abuse have similar symptom patterns, suggesting a relationship which can be used to distinguish these patients from those with drug-seeking behavior.

Cost-effectiveness analysis of the treatment of large leiomyomas: laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy.

OBJECTIVE: The purpose of this study was to perform a cost-effectiveness analysis comparing the treatment of large leiomyomas by laparoscopic assisted vaginal hysterectomy (LAVH) versus abdominal hysterectomy (AH). STUDY DESIGN: Twenty consecutive LAVH were compared to 20 consecutive AH for leiomyoma > or = 250 g. Hospital costs were obtained through Healthcare cost accounting system. The 6 principles of cost-effectiveness analysis were used. RESULTS: The groups were similar in respect to age, weight, race, medical comorbidities, blood loss, and operative time. Median uterine weight (513 g) was approximately 20% > for LAVH. Length of stay and pain was significantly less for LAVH. Total hospital cost for AH was approximately 12% less expensive ($4394 vs $5023, P = .18). CONCLUSION: Because of multiple benefits of LAVH versus AH and no significant difference in cost, we believe LAVH is an acceptable treatment for large leiomyoma.

Limbic associated pelvic pain: a hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain.

Limbic associated pelvic pain is a proposed pathophysiology designed to explain features commonly encountered in patients with chronic pelvic pain, including the presence of multiple pain diagnoses, the frequency of previous abuse, the minimal or discordant pathologic changes of the involved organs, the paradoxical effectiveness of many treatments, and the recurrent nature of the condition. These conditions include endometriosis, interstitial cystitis, irritable bowel syndrome, levator ani syndrome, pelvic floor tension myalgia, vulvar vestibulitis, and vulvodynia. The hypothesis is based on recent improvements in the understanding of pain processing pathways in the central nervous system, and in particular the role of limbic structures, especially the anterior cingulate cortex, hippocampus and amygdala, in chronic and affective pain perception. Limbic associated pelvic pain is hypothesized to occur in patients with chronic pelvic pain out of proportion to any demonstrable pathology (hyperalgesia), and with more than one demonstrable pain generator (allodynia), and who are susceptible to development of the syndrome. This most likely occurs as a result of childhood sexual abuse but may include other painful pelvic events or stressors, which lead to limbic dysfunction. This limbic dysfunction is manifest both as an increased sensitivity to pain afferents from pelvic organs, and as an abnormal efferent innervation of pelvic musculature, both visceral and somatic. The pelvic musculature undergoes tonic contraction as a result of limbic efferent stimulation, which produces the minimal changes found on pathological examination, and generates a further sensation of pain. The pain afferents from these pelvic organs then follow the medial pain pathway back to the sensitized, hypervigilant limbic system. Chronic stimulation of the limbic system by pelvic pain afferents again produces an efferent contraction of the pelvic muscles, thus perpetuating the cycle. This cycle is susceptible to disruption through blocking afferent signals from pelvic organs, either through anesthesia or muscle manipulation. Disruption of limbic perception with psychiatric medication similarly produces relief. Without a full disruption of both the central hypervigilance and pelvic organ dysfunction, pain recurs. To prevent recurrence, clinicians will need to include some form of therapy, either medical or cognitive, targeted at the underlying limbic hypervigilance. Further research into novel, limbic targeted therapies can hopefully be stimulated by explicitly stating the role of the limbic system in chronic pain. This hypothesis provides a framework for clinicians to rationally approach some of the most challenging patients in medicine, and can potentially improve outcomes by including management of limbic dysfunction in their treatment.

Induction of labor in women with a history of fast labor.

OBJECTIVE: History of fast labor is currently subjectively defined and inductions for non-medical indications are becoming restricted. We hypothesized that women induced for a history of fast labor do not have faster previous labors and do not deliver more quickly. METHODS: A retrospective case-control cohort design studied multiparas undergoing elective induction at one high risk center. Outcomes of dyads electively induced for a history of previous fast labor indication (PFast) were compared to controls with a psychosocial indication. RESULTS: A total of 612 elective inductions with 1074 previous deliveries were evaluated: 81 (13%) PFast and 531 (87%) control. PFast had faster previous labors (median 5.5 h, IQR: 4.5-6) versus. control (10 h, IQR: 9-10.5; p < 0.001). Subsequent delivery time from start to expulsion was shorter for PFast (median 7 h, IQR: 5-9, p < 0.001) than controls with and without a previous labor <5.5 h (8.6 h, IQR: 6-14 and 9.5 h, IQR: 7-15, respectively). PFast were less likely to have a serious maternal complication. Neonatal complications were similar. CONCLUSIONS: Patients induced for a history of fast labor do have faster previous labors, suggesting a significant history of fast labor can be defined as <5.5 h. These women deliver more quickly and with lower morbidity than controls when subsequently induced, therefore the benefit may warrant the risk for a select number of women with a history of a prior labor length <5.5 h.

The neurobiology of pain perception in normal and persistent pain.

Pain is a significant national burden in terms of patient suffering, expenditure and lost productivity. Understanding pain is fundamental to improving evaluation, treatment and innovation in the management of acute and persistent pain syndromes. Pain perception begins in the periphery, and then ascends in several tracts, relaying at different levels. Pain signals arrive in the thalamus and midbrain structures which form the pain neuromatrix, a constantly shifting set of networks and connections that determine conscious perception. Several cortical regions become active simultaneously during pain perception; activity in the cortical pain matrix evolves over time to produce a complex pain perception network. Dysfunction at any level has the potential to produce unregulated, persistent pain.

Classifying Patients with Chronic Pelvic Pain into Levels of Biopsychosocial Dysfunction Using Latent Class Modeling of Patient Reported Outcome Measures.

Chronic pelvic pain affects multiple aspects of a patient's physical, social, and emotional functioning. Latent class analysis (LCA) of Patient Reported Outcome Measures Information System (PROMIS) domains has the potential to improve clinical insight into these patients' pain. Based on the 11 PROMIS domains applied to n=613 patients referred for evaluation in a chronic pelvic pain specialty center, exploratory factor analysis (EFA) was used to identify unidimensional superdomains. Latent profile analysis (LPA) was performed to identify the number of homogeneous classes present and to further define the pain classification system. The EFA combined the 11 PROMIS domains into four unidimensional superdomains of biopsychosocial dysfunction: Pain, Negative Affect, Fatigue, and Social Function. Based on multiple fit criteria, a latent class model revealed four distinct classes of CPP: No dysfunction (3.2%); Low Dysfunction (17.8%); Moderate Dysfunction (53.2%); and High Dysfunction (25.8%). This study is the first description of a novel approach to the complex disease process such as chronic pelvic pain and was validated by demographic, medical, and psychosocial variables. In addition to an essentially normal class, three classes of increasing biopsychosocial dysfunction were identified. The LCA approach has the potential for application to other complex multifactorial disease processes.

Quantification of abdominal wall pain using pain pressure threshold algometry in patients with chronic pelvic pain.

OBJECTIVE: Chronic pelvic pain (CPP) is a syndrome involving 1 or more pain generating organs in the pelvis, which includes pain from the lower anterior abdominal wall. This entity has been termed myofascial pain syndrome (MFPS), but its characteristics, definition, and quantification have not been well described. In this study, pain pressure threshold (PPT) testing of the lower anterior abdominal wall in CPP patients was performed to determine the range and distribution of values at each site, and the clinical utility of using PPT in a definition of MFPS. METHODS: Fifty-six patients evaluated in a CPP specialty clinic underwent PPT algometry of 14 sites on the lower anterior abdominal wall. These values were described and evaluated before and after treatment. PPT values were also evaluated in patients found to be drug seeking. RESULTS: Twenty percent of the PPT tests reached the threshold of 3 kgf/cm2. The abnormal tests usually formed a normal distribution. PPT testing had a weak but appropriate correlation with other pain symptom measures. After trigger point injection there was a 75% improvement in PPT, and response to medical therapy resulted in a 60% improvement. A composite measure was able to distinguish drug-seeking patients with statistical accuracy. DISCUSSION: PPT testing can be used to evaluate MFPS in CPP patients. One suggested definition would exclude patients with low scores in the upper abdomen while including patients with low scores in the lower abdomen.

A preliminary study of transcranial direct current stimulation for the treatment of refractory chronic pelvic pain.

BACKGROUND: The modulatory effects of transcranial direct current stimulation (tDCS) appear beneficial for different chronic pain syndromes; however, it is unclear whether this method can be used to treat refractory chronic pelvic pain. OBJECTIVE: The objective of this preliminary study was to determine the efficacy and safety of tDCS for the management of refractory chronic pelvic pain. METHODS: Seven patients with chronic pelvic pain having failed standard medical or surgical therapy underwent a crossover, double-blind sham controlled tDCS treatment protocol consisting of 1 mA applied for 20 minutes on two consecutive days with 2 weeks of follow-up symptom recording. Symptoms were recorded using multiple scoring systems, including visual analog scales for different pains, as well as organ-specific symptom scales. Comparison between active and sham treatment was performed by using paired t tests. RESULTS: Overall and pelvic pain scores were significantly lower after active compared with sham treatment, as were disability and traumatic stress scores. No patient discontinued the study because of side effects, which were infrequent. CONCLUSIONS: Active tDCS treatment induces a modest pain reduction in refractory chronic pelvic pain patients as compared with sham tDCS treatment. These results can guide the design and implementation of further studies investigating this method of neuromodulation for the treatment of refractory chronic pelvic pain.

A method for the consistent creation and quantitative testing of postoperative pelvic adhesions in a porcine model.

INTRODUCTION: The assessment of methods for the prevention of postoperative pelvic adhesions is hampered by the lack of a quantifiable adhesion measurement technique. Currently available methods for adhesion model assessment rely on qualitative grading scales; a quantitative method would have many attendant benefits, including standardized reporting. METHODS: A technique was developed to generate consistent and significant adhesions in a swine model that are suitable for quantitative assessment using a Material Testing System (MTS) machine platform. In this method, the uterine horns are cannulated and then attached to the pelvic sidewall using loose silk sutures. The underlying sidewall and adjacent uterine serosa are injured with electrocautery. Following a two-week survival the entire complex of uterine horn and sidewall are excised en bloc and prepared for MTS testing. RESULTS: Extrication of the adhesion, as measured by the MTS platform, generates a quantitative assessment of adhesion strength that can be scaled and analyzed to produce several continuous variable descriptions. DISCUSSION: This technique represents a novel quantitative method for adhesion assessment in an animal model. This quantitative technique may then be applied to accurately assess a range of adhesion prevention techniques, producing results which can be standardized for comparison.

Receiver operating characteristic curves of symptom scores in the diagnosis of interstitial cystitis/painful bladder syndrome.

STUDY OBJECTIVE: Chronic pelvic pain is often a manifestation of interstitial cystitis (IC), for which several symptom scoring measures exist. However, the receiver operating characteristic (ROC) curves for these scores have not been described, even though such analysis could identify an optimal noninvasive test and suggest diagnostic test thresholds. The objective of this study was to develop ROC curves for IC symptom scores based on the standard of pain relief after cystoscopy with hydrodistention (HD). DESIGN: This is a retrospective analysis of IC symptom index (ICSI) and visual analog scale (VAS) bladder pain (VASb) scores recorded at initial patient visit. Patients underwent a diagnostic algorithm leading to selected HD. The ROC curves were calculated based on the presence of diagnostic criteria for IC found at HD (Canadian Task Force classification III). SETTING: A multidisciplinary chronic pelvic pain referral center. PATIENTS: A total of 277 women with chronic pelvic pain were evaluated. The mean duration of pain was 54 months; mean pelvic pain VAS score was 7.5. Those proved to have IC had a VASb score of 7 and an ICSI score of 11. INTERVENTIONS: Initial symptom score tabulation followed by a symptom-based diagnostic algorithm consisting of alkalinized lidocaine instillation with HD offered to responders. MEASUREMENTS AND MAIN RESULTS: The ROC curve for the VASb was shifted to the upper left compared with the ICSI, which was closer to the diagonal. Area under the curve was significantly greater for VASb (0.860) than ICSI (0.773) (p=.045). The maximum diagnostic accuracy for the ICSI was at a value of 14 or more (0.88) and for the VASb at a value of 7 or more (0.94). CONCLUSION: The most accurate symptom score for detecting IC based on this analysis was the VASb with a threshold of 7. Although the ICSI may have use, in this setting it is not as useful as the VAS for identifying patients who eventually prove to have IC.

Phase I/II prospective trial of autologous platelet tissue graft in gynecologic surgery.

STUDY OBJECTIVE: To perform the original phase I/II trial of autologous platelet tissue graft in gynecologic surgery to evaluate toxicity and efficacy on decreasing pain. DESIGN: Prospective nonrandomized trial (Canadian Task Force classification II-A). SETTING: Teaching hospital. PATIENTS: Fifty-five consecutive patients undergoing major gynecologic surgery were entered into this prospective phase I/II trial and were matched with 55 patients from the previous 6 months. INTERVENTION: After anesthesia was induced, peripheral venous blood (55 mL) was obtained from the patient producing, autologous platelet tissue graft (20 mL). At completion of surgery, autologous platelet tissue graft was directly applied to the surgical site. MEASUREMENTS AND MAIN RESULTS: Median pain on the day of surgery was 2.7 (mild) in the autologous platelet tissue graft group vs 6.7 (severe) in the control group, p <.001. Likewise, pain on postoperative day 1 was 2.1 (mild) in the autologous platelet tissue graft group vs 5.5 (moderate) in the control group, p < or =.001. Median of morphine per hospital stay for the autologous platelet tissue graft group was 17 mg (range 1-98 mg) vs 26 mg (range 3-90 mg) in the control group, which was statistically significant at p = .02. There were no adverse effects associated with autologous platelet tissue graft. CONCLUSIONS: In the original phase I/II prospective trial of autologous platelet tissue graft in gynecologic surgery, there were no apparent adverse effects, and pain was significantly reduced.

A laparoscopic bipolar cutting forceps can assist in a case of difficult vaginal hysterectomy.

A vaginal approach to hysterectomy can become challenging when visualization is limited by poor or absent uterine descent, obesity, or other factors that make an approach to the uterine pedicles difficult. When factors occur that make application or visualization of conventional vaginal instruments difficult, using an instrument designed for laparoscopic application, with its thin, elongated shape, may permit continuation of a vaginal approach. In such a case, a Gyrus bipolar laparoscopic cutting forceps was used for coagulation and transection of the uterine pedicles during a vaginal hysterectomy. This represents a way to expand on traditional techniques for completion of difficult vaginal hysterectomy, which may be used concurrently. Surgical techniques that more easily and safely permit completion of hysterectomy by the vaginal approach can improve outcomes for all.