Dissociation Among Women with Chronic Pelvic Pain: Relation to Surgical Treatment, Pelvic Pain Severity, and Health-Related Quality of Life.

Chronic pelvic pain (CPP) is associated with a history of trauma and symptoms of somatoform dissociation. We aimed to describe how somatoform dissociation impacts CPP symptoms, surgical treatment, and health-related quality of life (HRQOL). Patients (N = 133) diagnosed with CPP presenting for an appointment at a women's health clinic between November, 2019 - July, 2021 were recruited to participate in a cross-sectional study and complete a survey assessing symptoms of somatoform dissociation, post-traumatic stress disorder (PTSD), pelvic pain severity, history of CPP-related surgeries, and mental and physical HRQOL. We also conducted a post-hoc analysis assessing correlations of individual symptom items on the Somatoform Dissociation Questionnaire (SDQ-20) with HRQOL outcomes. We did not find a relationship between somatoform dissociation and pelvic pain severity or surgical history. Physical HRQOL outcomes were related to somatoform dissociation, PTSD symptoms, and pelvic pain severity, while mental HRQOL outcomes were connected to somatoform dissociation and PTSD symptoms. Our study reveals preliminary evidence suggesting that among CPP patients, HRQOL outcomes are affected by unique profiles of positive and negative symptoms of somatoform dissociation, including sensory disturbances, localized genital pain, and generalized numbness and bodily analgesia. Addressing specific symptoms of somatoform dissociation may enhance HRQOL among trauma-exposed women with CPP. Replication studies are needed to validate our findings. Integrating trauma-informed approaches, including standardized evaluations of trauma exposure and symptoms of somatoform dissociation into routine care for women with CPP is encouraged.

Childhood betrayal trauma, dissociation, and shame impact health-related quality of life among individuals with chronic pelvic pain.

BACKGROUND: High betrayal trauma (HBT), or interpersonal trauma perpetrated by someone close, is linked to dissociation and shame, while trauma perpetrated by someone less close, low betrayal trauma (LBT) is associated with post-traumatic stress disorder (PTSD). OBJECTIVE: Child interpersonal trauma is common among women with chronic pelvic pain (CPP) and can negatively impact physical and mental health-related quality of life (HRQOL). Our study investigates unexplored connections between these variables. PARTICIPANTS & SETTING: Survey data were analyzed from 96 English-speaking female patients with CPP at a women's health clinic (mean age = 33, 59 % White non-Hispanic, 62 % married or cohabitating, 61.5 % completed post-high school degree); prevalence of HBT and LBT were 65.2 % and 45.6 %, respectively. METHODS: Multiple regression analyzed relationships between mental and physical HRQOL and dissociation, shame, and PTSD. Parallel mediation analyses examined indirect relationships between mental and physical HRQOL and exposure to childhood HBT and LBT. RESULTS: Dissociation was related to worse physical HRQOL, while shame was related to worse physical and mental HRQOL. Dissociation and shame mediated relationships between childhood HBT and current mental (R2 = 0.08, p = .01) and physical (R2 = 0.11, p = .002) HRQOL. Shame, but not PTSD, mediated relationships between childhood LBT and current mental (R2 = 0.14, p < .001) and physical (R2 = 0.16, p < .001) HRQOL. CONCLUSIONS: Our study provides preliminary evidence that dissociation and shame negatively impact HRQOL among individuals with CPP in the context of exposure to different types of childhood betrayal trauma. Replication studies to validate our results with larger samples and longitudinal designs are encouraged.

When and How to Utilize Pudendal Nerve Blocks for Treatment of Pudendal Neuralgia.

Chronic pelvic pain is a common cause of pain in reproductive age women with debilitating consequences for affected women's health and quality of life. Treatment providers must be well versed in all treatment options for these patients, understanding the overlap in the management and treatment of chronic pelvic pain caused by pudendal neuralgia, myofascial pelvic pain, and vulvodynia. Pudendal blocks are a simple and quick procedure that can be performed in the office and often helps improve all the above conditions when used along with other treatment options. We review the anatomy and methodology on when and how to perform pudendal blocks in the office to better inform the general gynecologist on how to implement offering this treatment in the outpatient clinical setting.

Postoperative Risks for Hispanic Patients Undergoing Hysterectomy for Benign Indications.

BACKGROUND: Hispanic patients have previously been shown to have relatively lower odds of complication following hysterectomy compared with non-Hispanic white patients, but little is known about specific risks for this group. Our primary objective was to identify differences in proportions of specific complications experienced by Hispanic patients following hysterectomy for benign indications as compared with non-Hispanic white patients. DESIGN: Retrospective cohort study examining differences in complication rates following benign hysterectomy between Hispanic and non-Hispanic white patients in NSQIP-participating hospitals from 2012 to 2016. MEASUREMENTS AND MAIN RESULTS: A total of 102,051 women were included. A total of 15.0% were Hispanic and 85.0% were non-Hispanic white. Hispanic patients were more likely to have class 1 or 2 obesity (59.7 vs 49.8%), diabetes (10.9 vs 6.7%), and anemia (hematocrit < 33: 14.1 vs 6.5%); p < 0.01 for all. Hispanic patients were more likely to undergo abdominal hysterectomy (30.0 vs 19.1%, p < 0.01) and to remain inpatient for 2-6 days (38.8 vs 24.0%, p < 0.01). After adjustment for possible confounders including anemia, an increased odds of requiring blood transfusion persisted only in the laparoscopic and vaginal groups. Hispanic patients had a decreased or equal odds for all other examined complications. CONCLUSIONS: Compared with non-Hispanic white patients, Hispanic women had a higher odds of requiring blood transfusion even when undergoing minimally invasive laparoscopic and vaginal approaches to hysterectomy. Despite a higher proportion of open surgery, Hispanic patients had a decreased or equal odds of postoperative complications.

Office Operative Hysteroscopy: An Update.

Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.

A comprehensive review of Asherman's syndrome: causes, symptoms and treatment options.

PURPOSE OF REVIEW: Intrauterine adhesions, also known as Asherman's syndrome, can have an impact on both reproductive outcomes and gynaecologic symptoms. Understanding the cause of intrauterine adhesions and the common clinical presentation will increase awareness of the condition and guide the patient to appropriate therapy. Surgical management offers favourable fertility outcomes and is often successful in restoring menstruation. RECENT FINDINGS: Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment and adopting an office-based approach offers several advantages. Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority. Cell-based therapies using endometrial stem/progenitor cells hold promise for future use in regenerating inadequate endometrium. SUMMARY: Increased awareness of the symptoms suggestive of intrauterine adhesive disease, as well as recognition of common causes and preceding events, is crucial for early diagnosis, patient counselling and treatment. VIDEO ABSTRACT: http://links.lww.com/COOG/A36.

SCN5A variant that blocks fibroblast growth factor homologous factor regulation causes human arrhythmia.

Nav channels are essential for metazoan membrane depolarization, and Nav channel dysfunction is directly linked with epilepsy, ataxia, pain, arrhythmia, myotonia, and irritable bowel syndrome. Human Nav channelopathies are primarily caused by variants that directly affect Nav channel permeability or gating. However, a new class of human Nav channelopathies has emerged based on channel variants that alter regulation by intracellular signaling or cytoskeletal proteins. Fibroblast growth factor homologous factors (FHFs) are a family of intracellular signaling proteins linked with Nav channel regulation in neurons and myocytes. However, to date, there is surprisingly little evidence linking Nav channel gene variants with FHFs and human disease. Here, we provide, to our knowledge, the first evidence that mutations in SCN5A (encodes primary cardiac Nav channel Nav1.5) that alter FHF binding result in human cardiovascular disease. We describe a five*generation kindred with a history of atrial and ventricular arrhythmias, cardiac arrest, and sudden cardiac death. Affected family members harbor a novel SCN5A variant resulting in p.H1849R. p.H1849R is localized in the central binding core on Nav1.5 for FHFs. Consistent with these data, Nav1.5 p.H1849R affected interaction with FHFs. Further, electrophysiological analysis identified Nav1.5 p.H1849R as a gain-of-function for INa by altering steady-state inactivation and slowing the rate of Nav1.5 inactivation. In line with these data and consistent with human cardiac phenotypes, myocytes expressing Nav1.5 p.H1849R displayed prolonged action potential duration and arrhythmogenic afterdepolarizations. Together, these findings identify a previously unexplored mechanism for human Nav channelopathy based on altered Nav1.5 association with FHF proteins.

Cellular energy depletion resets whole-body energy by promoting coactivator-mediated dietary fuel absorption.

All organisms have devised strategies to counteract energy depletion and promote fitness for survival. We show here that cellular energy depletion puts into play a surprising strategy that leads to absorption of exogenous fuel for energy repletion. The energy-depletion-sensing kinase AMPK binds, phosphorylates, and activates the transcriptional coactivator SRC-2, which in a liver-specific manner promotes absorption of dietary fat from the gut. Hepatocyte-specific deletion of SRC-2 results in intestinal fat malabsorption and attenuated entry of fat into the blood stream. This defect can be attributed to AMPK- and SRC-2-mediated transcriptional regulation of hepatic bile acid (BA) secretion into the gut, as it can be completely rescued by replenishing intestinal BA or by genetically restoring the levels of hepatic bile salt export pump (BSEP). Our results position the hepatic AMPK-SRC-2 axis as an energy rheostat, which upon cellular energy depletion resets whole-body energy by promoting absorption of dietary fuel.

Biventricular and novel pacing mechanisms in heart failure.

Biventricular pacing, often referred to as cardiac resynchronization therapy (CRT), improves subjective and objective measures and promotes reverse ventricular remodeling in patients with chronic New York Heart Association (NYHA) class III or IV heart failure despite optimal medical therapy, QRS duration of more than 130 ms, and left ventricular ejection fraction of less than 35%. However, there are many nonresponders and other patients who do not meet criteria for CRT, limiting the efficacy of therapy. Recent investigations (eg, the REVERSE trial) have shown that patients with minimal symptoms (NYHA class I-II) can benefit from the mechanical and functional effects of CRT, specifically reverse remodeling. Ongoing investigations include the possibility of earlier intervention in the postinfarct period with CRT. Additionally, a novel pacing mechanism known as cardiac contractility modulation has also shown promise in improving remodeling of the failing heart. In this article, we review CRT's effects on reverse remodeling in an expanding patient population and as a novel pacing mechanism, its cardiac contractility modulation, and its benefits in patients with heart failure.