Current outcomes of blunt open pelvic fractures: how modern advances in trauma care may decrease mortality.

Background:Open pelvic fracture, caused by a blunt mechanism, is an uncommon injury with a high mortality rate. In 2008, evidence-based algorithm for managing pelvic fractures in unstable patients was published by the Western Trauma Association (WTA). The use of massive transfusion protocols has become widespread as has the availability and use of pelvic angiography. The purpose of this study was to evaluate the outcome of open pelvic fractures in association with related advances in trauma care. Methods:A retrospective review was performed, at an American College of Surgeon verified level I trauma center, of patients with blunt open pelvic fractures from January 2010 to April 2016. The WTA algorithm, including massive transfusion protocol, and pelvic angiography were uniformly used. Data collected included injury severity score, demographic data, transfusion requirements, use of pelvic angiography, length of stay, and disposition. Data were compared with a similar study from 2005. Results:During the study period, 1505 patients with pelvic fractures were analyzed; 87 (6%) patients had open pelvic fractures. Of these, 25 were from blunt mechanisms and made up the study population. Patients in both studies had similar injury severity scores, ages, Glasgow Coma Scale, and gender distributions. Use of angiography was higher (44% vs. 16%; P=0.011) and mortality was lower (16% vs. 45%; P=0.014) than in the 2005 study. Conclusions:Changes in trauma care for patients with open blunt pelvic fracture include the use of an evidence-based algorithm, massive transfusion protocols and increased use of angioembolization. Mortality for open pelvic fractures has decreased with these advances. Level of evidence:Level IV

Variation in pelvic morphology may prevent the identification of anterior pelvic tilt

Pelvic tilt is often quantified using the angle between the horizontal and a line connecting the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS). Although this angle is determined by the balance of muscular and ligamentous forces acting between the pelvis and adjacent segments, it could also be influenced by variations in pelvic morphology. The primary objective of this anatomical study was to establish how such variation may affect the ASIS-PSIS measure of pelvic tilt. In addition, we also investigated how variability in pelvic landmarks may influence measures of innominate rotational asymmetry and measures of pelvic height. Thirty cadaver pelves were used for the study. Each specimen was positioned in a fixed anatomical reference position and the angle between the ASIS and PSIS measured bilaterally. In addition, side-to-side differences in the height of the innominate bone were recorded. The study found a range of values for the ASIS-PSIS of 0–23 degrees, with a mean of 13 and standard deviation of 5 degrees. Asymmetry of pelvic landmarks resulted in side-to-side differences of up to 11 degrees in ASISPSIS tilt and 16 millimeters in innominate height. These results suggest that variations in pelvic morphology may significantly influence measures of pelvic tilt and innominate rotational asymmetry

The effects of childbirth on the pelvic-floor

Basically, vaginal delivery is associated with the risk of pelvic floor damage. The pelvic floor sequelae of childbirth includes anal incontinence, urinary incontinence and pelvic organ prolapse. Pathophysiology, incidence and risk factors for the development of the respective problems are reviewed. Where possible, recommendations for reducing the risk of pelvic floor damage are given

Uncovering changes in proteomic signature of rat pelvic floor muscles in pregnancy.

BackgroundStructural and functional changes of the rat pelvic floor muscles during pregnancy, specifically, sarcomerogenesis, increase in extracellular matrix content, and higher passive tension at larger strains protect the integral muscle components against birth injury. The mechanisms underlying these antepartum alterations are unknown. Quantitative proteomics is an unbiased method of identifying protein expression changes in differentially conditioned samples. Therefore, proteomics analysis provides an opportunity to identify molecular mechanisms underlying antepartum muscle plasticity.ObjectiveTo elucidate putative mechanisms accountable for pregnancy-induced adaptations of the pelvic floor muscles, and to identify other novel antepartum alterations of the pelvic floor muscles.Materials and methodsPelvic floor muscles, comprised of coccygeus, iliocaudalis, and pubocaudalis, and nonpelvic limb muscle, tibialis anterior, were harvested from 3-month-old nonpregnant and late-pregnant Sprague-Dawley rats. After tissue homogenization, trypsin-digested peptides were analyzed by ultra-high-performance liquid chromatography coupled with tandem mass spectroscopy using nano-spray ionization. Peptide identification and label free relative quantification analysis were carried out using Peaks Studio 8.5 software (Bioinformatics Solutions Inc., Waterloo, ON, Canada). Proteomics data were visualized using the Qlucore Omics Explorer (New York, NY). Differentially expressed peptides were identified using the multi-group differential expression function, with q-value cutoff set at <0.05. Proteomic signatures of the pelvic floor muscles were compared to nonpelvic limb muscle and between nonpregnant and pregnant states.ResultsUnsupervised clustering of the data showed clear separation between samples from nonpregnant and pregnant animals along principal component 1 and between pelvic and nonpelvic muscles along principal component 2. Four major gene clusters were identified segregating proteomic signatures of muscles examined in nonpregnant vs pregnant states: (1) proteins increased in the pelvic floor muscles only; (2) proteins increased in the pelvic floor muscles and tibialis anterior; (3) proteins decreased in the pelvic floor muscles and tibialis anterior; and (4) proteins decreased in the pelvic floor muscles alone. Cluster 1 included proteins involved in cell cycle progression and differentiation. Cluster 2 contained proteins that participate in mitochondrial metabolism. Cluster 3 included proteins involved in transcription, signal transduction, and phosphorylation. Cluster 4 comprised proteins involved in calcium-mediated regulation of muscle contraction via the troponin tropomyosin complex.ConclusionPelvic floor muscles gain a distinct proteomic signature in pregnancy, which provides a mechanistic foundation for the antepartum physiological alterations acquired by these muscles. Variability in genes encoding these proteins may alter plasticity of the pelvic floor muscles and therefore the extent of the protective pregnancy-induced adaptations. Furthermore, pelvic floor muscles' proteome is divergent from that of the nonpelvic skeletal muscles

Screening for Gynecologic Conditions With Pelvic Examination US Preventive Services Task Force Recommendation Statement

IMPORTANCE Many conditions that can affect women\u27s health are often evaluated through pelvic examination. Although the pelvic examination is a common part of the physical examination, it is unclear whether performing screening pelvic examinations in asymptomatic women has a significant effect on disease morbidity and mortality. OBJECTIVE To issue a new US Preventive Services Task Force(USPSTF) recommendation on screening for gynecologic conditions with pelvic examination for conditions other than cervical cancer, gonorrhea, and chlamydia, for which the USPSTF has already made specific recommendations. EVIDENCE REVIEW The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women 18 years and older who are not at increased risk for any specific gynecologic condition. FINDINGS Overall, the USPSTF found inadequate evidence on screening pelvic examinations for the early detection and treatment of a range of gynecologic conditions in asymptomatic, nonpregnant adult women. CONCLUSIONS AND RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women. (I statement) This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou smear, screening for gonorrhea and chlamydia)

Altered resting state neuromotor connectivity in men with chronic prostatitis/chronic pelvic pain syndrome: A MAPP: Research Network Neuroimaging Study.

Brain network activity associated with altered motor control in individuals with chronic pain is not well understood. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a debilitating condition in which previous studies have revealed altered resting pelvic floor muscle activity in men with CP/CPPS compared to healthy controls. We hypothesized that the brain networks controlling pelvic floor muscles would also show altered resting state function in men with CP/CPPS. Here we describe the results of the first test of this hypothesis focusing on the motor cortical regions, termed pelvic-motor, that can directly activate pelvic floor muscles. A group of men with CP/CPPS (N = 28), as well as group of age-matched healthy male controls (N = 27), had resting state functional magnetic resonance imaging scans as part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network study. Brain maps of the functional connectivity of pelvic-motor were compared between groups. A significant group difference was observed in the functional connectivity between pelvic-motor and the right posterior insula. The effect size of this group difference was among the largest effect sizes in functional connectivity between all pairs of 165 anatomically-defined subregions of the brain. Interestingly, many of the atlas region pairs with large effect sizes also involved other subregions of the insular cortices. We conclude that functional connectivity between motor cortex and the posterior insula may be among the most important markers of altered brain function in men with CP/CPPS, and may represent changes in the integration of viscerosensory and motor processing

Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain.

Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and successfully treating MFPP

Pelvic floor disorders in gynecological malignancies. An overlooked problem?

Cervical, endometrial, ovarian, vulvar, and vaginal cancers affect women of a broad age spectrum. Many of these women are still sexually active when their cancer is diagnosed. Treatment options for gynecological malignancies, such as gynecological surgery, radiation, and chemotherapy, are proven risk factors for pelvic floor dysfunction. The prevalence of urinary incontinence, fecal incontinence, and sexual dysfunction before cancer treatment is still unclear. Hypotheses have been raised in the literature that these manifestations could represent early symptoms of pelvic cancers, but most remain overlooked even in cancer surviving patients. The primary focus of therapy is always cancer eradication, but as oncological and surgical treatment options become more successful, the number of cancer survivors increases. The quality of life of patients with gynecological cancers often remains an underrated subject. Pelvic floor disorders are not consistently reported by patients and are frequently overlooked by many clinicians. In this brief review we discuss the importance of pelvic floor dysfunction in patients with gynecological malignant tumors

Head and pelvic movement asymmetry during lungeing in horses with symmetrical movement on the straight

REASONS FOR PERFORMING STUDY: Lungeing is commonly used as part of standard lameness examinations in horses. Knowledge of how lungeing influences motion symmetry in sound horses is needed. OBJECTIVES: The aim of this study was to objectively evaluate the symmetry of vertical head and pelvic motion during lungeing in a large number of horses with symmetric motion during straight line evaluation. STUDY DESIGN: Cross‐sectional prospective study. METHODS: A pool of 201 riding horses, all functioning well and considered sound by their owners, were evaluated in trot on a straight line and during lungeing to the left and right. From this pool, horses with symmetric vertical head and pelvic movement during the straight line trot (n = 94) were retained for analysis. Vertical head and pelvic movements were measured with body mounted uniaxial accelerometers. Differences between vertical maximum and minimum head (HDmax, HDmin) and pelvic (PDmax, PDmin) heights between left and right forelimb and hindlimb stances were compared between straight line trot and lungeing in either direction. RESULTS: Vertical head and pelvic movements during lungeing were more asymmetric than during trot on a straight line. Common asymmetric patterns seen in the head were more upward movement during push‐off of the outside forelimb and less downward movement during impact of the inside limb. Common asymmetric patterns seen in the pelvis were less upward movement during push‐off of the outside hindlimb and less downward movement of the pelvis during impact of the inside hindlimb. Asymmetric patterns in one lunge direction were frequently not the same as in the opposite direction. CONCLUSIONS: Lungeing induces systematic asymmetries in vertical head and pelvic motion patterns in horses that may not be the same in both directions. These asymmetries may mask or mimic fore‐ or hindlimb lameness

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction

There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report.This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper.A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible.A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research