Latent profile analysis of pelvic floor muscle pain in patients with chronic pelvic pain.

AIM: Chronic pelvic pain (CPP) is a syndrome of related diagnoses including pain originating from the muscles of the pelvic floor. The objective of this study was to evaluate which muscles are important to examine, in what manner pelvic floor muscle pain contributes to patients' pain experience, or what thresholds should be applied to identify significant pelvic floor muscle pain by comparing exam findings with outcome measures METHODS: A total of 428 patients meeting the definition for CPP were evaluated using a standardized physical examination of the abdominal wall, pelvic floor, and vestibule along with the 12 domain Patient Reported Outcome Measures Information System (PROMIS). These scores were evaluated for unidimensionality followed by latent profile analysis. The areas under the receiver operator characteristic curves were used to identify the best pain threshold for each muscle. RESULTS: The eight pelvic floor muscle sites all loaded onto a single factor, separate from other areas examined. Two latent classes were found within all the variables. Patients in the severe pelvic floor pain class had significantly worse pain related PROMIS scores. Optimal thresholds for identifying significant pelvic floor pain ranged between 3 and 5. CONCLUSION: Pain in the pelvic floor muscles is distinguishable from pain in the abdominal wall and vulva. Any of the lateral muscle sites evaluated can be used to identify patients with significant pelvic floor pain. Two latent classes of CPP patients were identified: those with limited and those with severe pain, as identified by moderate to severe pelvic floor tenderness.

Phenotyping chronic pelvic pain based on latent class modeling of physical examination.

Introduction. Defining clinical phenotypes based on physical examination is required for clarifying heterogeneous disorders such as chronic pelvic pain (CPP). The objective of this study was to determine the number of classes within 4 examinable regions and then establish threshold and optimal exam criteria for the classes discovered. Methods. A total of 476 patients meeting the criteria for CPP were examined using pain pressure threshold (PPT) algometry and standardized numeric scale (NRS) pain ratings at 30 distinct sites over 4 pelvic regions. Exploratory factor analysis, latent profile analysis, and ROC curves were then used to identify classes, optimal examination points, and threshold scores. Results. Latent profile analysis produced two classes for each region: high and low pain groups. The optimal examination sites (and high pain minimum thresholds) were for the abdominal wall region: the pair at the midabdomen (PPT threshold depression of > 2); vulvar vestibule region: 10:00 position (NRS > 2); pelvic floor region: puborectalis (combined NRS > 6); vaginal apex region: uterosacral ligaments (combined NRS > 8). Conclusion. Physical examination scores of patients with CPP are best categorized into two classes: high pain and low pain. Standardization of the physical examination in CPP provides both researchers and general gynecologists with a validated technique.

Chronic pelvic pain syndrome-related diagnoses in an outpatient office setting.

BACKGROUND: Chronic pelvic pain (CPP) is a syndrome composed of one or more pain diagnoses arising from pelvic organs. Although the prevalence of many individual diagnoses has been determined in a variety of settings, the concurrent assessment of overlapping pain syndromes in an outpatient gynecology clinic, which would be most pertinent to practitioners, has not been reported. METHODS: Patients waiting to be seen in an outpatient general gynecology clinic completed a survey composed of validated instruments for different pain diagnoses. Cyclic and constant CPP, irritable bowel syndrome (IBS), interstitial cystitis (IC), and vulvodynia (VVD) were assessed. RESULTS: In the 498 completed surveys, 24% of patients met at least one criterion for CPP, and of these, 23% also met criteria for a second diagnosis. Of all patients, 15% reported symptoms consistent with IBS, 6% with IC, and 5% with VVD. Cyclic CPP was found in 20%, and of these patients, 30% had at least one other CPP-related diagnosis. DISCUSSION: Although limited by its design as a survey, this study demonstrates that CPP frequently (between 30 and 43%) occurs with other pain syndromes. Clinicians should be prepared to evaluate nongynecologic causes of pelvic pain.

The fetus at term: in utero volume-selected proton MR spectroscopy with a breath-hold technique--a feasibility study.

In three healthy gravidas at 38 and 39 weeks gestation, fetal MR spectroscopy was performed with a breath-hold technique by using the following pulse sequences: single voxel point-resolved spectroscopy, or PRESS, for liver and heart studies and stimulated-echo acquisition mode, or STEAM, for brain studies. Signal peaks of lipid from heart and liver were detected, as were the signal peaks of choline, creatine, and N-acetylaspartate from fetal brain. Findings demonstrated the feasibility of performing proton MR spectroscopy to assess mobile fetal structures.

Magnetic resonance spectroscopy to detect lecithin in amniotic fluid and fetal lung.

BACKGROUND: Proton magnetic resonance spectroscopy is a noninvasive technique that detects molecules within a specified region in vivo. Lecithin, the major component of surfactant, has a characteristic magnetic resonance signal, but to our knowledge, it has never been reported in fetal lung or amniotic fluid (AF). The objective of this study was to characterize the lecithin signal in utero, which could lead to a noninvasive fetal lung maturity test. METHOD: Human fetal lung and AF pockets can be identified and studied with magnetic resonance spectroscopy with the use of a 1.5-tesla Vision whole-body magnetic resonance scanner (Siemens Medical Systems; Erlangen, Germany). Spectroscopy data are collected with a single-voxel-point-resolved spectroscopy sequence. After identification of fetal anatomy with the use of scout magnetic resonance images, magnetic resonance spectroscopy of human fetal lung and AF identifies a lecithin peak. EXPERIENCE: Three healthy gravidas near term were studied and lecithin peaks were identified in all. CONCLUSION: Lecithin can be identified in vivo with the use of volume-selected proton magnetic resonance spectroscopy. Patient comfort and extremely short scan times suggest that refined magnetic resonance spectroscopy might be a safe, quick, and comfortable test of fetal lung maturity.

Lecithin can be detected by volume-selected proton MR spectroscopy using a 1.5 T whole body scanner: a potentially non-invasive method for the prenatal assessment of fetal lung maturity.

The prenatal determination of fetal lung maturity is currently assessed by chemical analysis of surfactant associated lipids from aminotic fluid obtained by amniocentesis. This is an invasive procedure with rare but occasionally serious morbidity. Magnetic resonance spectroscopy (MRS) is a non-invasive method for the in vivo localization and identification of molecules with known resonance peaks at specified chemical shifts. In this report we examine the in vitro MRS of a lecithin/saline solution as well as term and preterm amniotic fluid samples with the use of a 1.5 T whole body scanner and a flexible surface coil. We found that amniotic fluid at term demonstrates a resonance peak at 3.2 ppm which was the same as the chemical shift of lecithin in saline. The lecithin peak is not observed in preterm amniotic fluid. This demonstrates the feasibility of using MRS with a whole body scanner to detect lecithin, one of the markers for fetal lung maturity.

Isolation and characterization of an insulin-degrading enzyme from Drosophila melanogaster.

An insulin-degrading enzyme (IDE) from the cytoplasm of Drosophila Kc cells has been purified and characterized. The purified enzyme is a monomer with an s value of 7.2 S, an apparent Km for porcine insulin of 3 microM, and a specific activity of 3.3 nmol of porcine insulin degraded/(min.mg). N-Terminal sequence analysis of the gel-purified enzyme gave a single, serine-rich sequence. The Drosophila IDE shares a number of properties in common with its mammalian counterpart. The enzyme could be specifically affinity-labeled with [125I]insulin, has a molecular weight of 110K, and has a pI of 5.3. Although Drosophila Kc cells grow at room temperature, the optimal enzyme activity assay conditions parallel those of the mammalian IDE: 37 degrees C and a pH range of 7-8. The Drosophila IDE activity, like the mammalian enzymes, is inhibited by bacitracin and sulfhydryl-specific reagents. Similarly, the Drosophila IDE activity is insensitive to glutathione as well as protease inhibitors such as aprotinin and leupeptin. Insulin-like growth factor II, equine insulin, and porcine insulin compete for degradation of [125I]insulin at comparable concentrations (approximately 10(-6) M), whereas insulin-like growth factor I and the individual A and B chains of insulin are less effective. The high degree of evolutionary conservation between the Drosophila and mammalian IDE suggests an important role for this enzyme in the metabolism of insulin and also provides further evidence for the existence of a complete insulin-like system in invertebrate organisms such as Drosophila.

Single-dose amoxicillin therapy with follow-up urine culture. Effective initial management for acute uncomplicated urinary tract infections.

To learn whether a single dose of amoxicillin is safe, effective therapy for acute uncomplicated urinary tract infections, 388 symptomatic nonpregnant women were randomly grouped to receive oral amoxicillin, either as a single 3 g dose of 250 mg three times a day for two weeks. Patients had quantitative as well as dip-slide cultures of urine and tests for antibody-coated bacteria in urine. Follow-up urine cultures were obtained one week after completion of treatment. Results of antimicrobial susceptibility and antibody-coated bacterial tests did not alter the randomized therapy. Among 162 patients with bacteriologically confirmed infections, cure rates were 60.6 percent (43 of 71) for single-dose versus 73.6 percent (67 of 91) for two-week treatment (p = 0.07). Although more antibody-coated bacteria-negative patients (89.6 percent; 26 of 29) were cured overall, a substantial proportion of antibody-coated bacteria-positive patients were also cured by both single-dose (59.3 percent; 32 of 54) and 14-day therapy (64.6 percent; 42 of 65). There were fewer adverse effects in the single-dose treatment group. We conclude that a single 3 g dose of amoxicillin, with follow-up urine culture, provides safe and effective management for acute uncomplicated urinary tract infections in nonpregnant women.