Objectives Vaginal delivery is a risk factor in pelvic floor disorders. We previously described changes in the pelvic floor associated with pregnancy and parturition in the squirrel monkey, a species with a human-like pattern of spontaneous age and parity associated pelvic organ prolapse. The potential to prevent or diminish these changes with scheduled cesarean section has not been evaluated. In a randomized, controlled trial, we compare female squirrel monkeys undergoing spontaneous vaginal delivery with those undergoing scheduled primary cesarean section for pelvic floor muscle volumes, muscle contrast changes, and dynamic effects on bladder neck position. Study Design Levator ani, obturator internus, and coccygeus muscle volumes and contrast uptake were assessed by magnetic resonance imaging in 20 nulliparous females examined prior to pregnancy, a few days after delivery, and 3 months post-partum. The position of bladder neck relative to boney reference line also was assessed with abdominal pressure using dynamic magnetic resonance imaging. Results Baseline measurements of 10 females randomly assigned to scheduled primary cesarean sections were not different from those of 10 females assigned to spontaneous vaginal delivery. Levator ani and obturator internus muscle volumes did not differ between groups, while volumes were reduced (p < 0.05) in the observation immediately after pregnancy. The coccygeus muscles increased (p < 0.05) immediately after delivery for females in the spontaneous vaginal delivery group, but not for females in the scheduled cesarean section group. Position of the bladder neck descended (p < 0.05) by 3 months post-partum in both groups. Conclusions Scheduled cesarean delivery diminishes changes in coccygeus muscle volume and contrast reported to be associated with spontaneous vaginal delivery in squirrel monkeys. However, pelvic support of the bladder was not protected by this intervention suggesting that effects of pregnancy and delivery are not uniformly prevented by this procedure.
Vemurafenib is a selected BRAF kinase inhibitor approved for treating metastatic or unresectable melanoma, which has numerous cutaneous side effects unfortunately, including three previously reported cases of asymptomatic areola and/or nipple hyperkeratosis. We present the first case of painful bilateral nipple hyperkeratosis secondary to vemurafenib in an 84-year-old woman. She was successfully treated with tretinoin 0.05% cream that allowed her to comfortably continue treatment. With increased awareness of this condition, we found a second case of asymptomatic nipple hyperkeratosis secondary to vemurafenib in our clinic. As this medication gains acceptance for treatment of metastatic melanoma, it is imperative that dermatologists are aware of this potentially uncomfortable side effect that can result in decreased compliance and impaired quality of life.
Complex regional pain syndrome (CRPS) is a neurologic disorder that often results in debilitating chronic pain, but the diagnosis may elude providers as it is one of exclusion. A history of trauma may be elucidated. We report a case of CRPS and review the clinical findings, appropriate workup, and treatment options for the patient. The patient we describe went through an extensive workup before receiving the correct diagnosis. Delay in diagnosis leads to prolonged suffering for the patient and, at times, unnecessary invasive debridement procedures. Raising awareness of this entity may help physicians make the correct diagnosis early, as well as initiate a collaborative effort between neurology, anesthesiology, and dermatology to provide the patient the most favorable outcome. W e present a case of complex regional pain syndrome (CRPS) in a 41-year-old man to highlight the importance of early recognition and diagnosis to reduce the signifi cant morbidity associated with this disease. CASE DESCRIPTIONA 41-year-old white man presented to the emergency department with a severely painful, nonhealing ulceration on his left index fi nger after cutting his fi nger on bailing wire. He was evaluated in an emergency department and discharged. He returned several days later with increasing redness and pain, received a dose of intravenous vancomycin, and was discharged with oral trimethoprim/sulfamethoxazole. Several days later, the worsening pain was so severe that he requested amputation of his fi nger. Upon admission, his wound was debrided in the operating room. After several days of intravenous vancomycin, he was discharged with oral minocycline. All wound cultures performed over the course of his hospitalizations were negative for pathogens. Upon his fourth presentation, still in excruciating pain, the dermatology service was consulted for body tissue culture. Examination of his left index fi nger revealed a dry, heme-crusted ulceration with surrounding erythema and violaceous edema ( Figure ) . He was otherwise healthy, but did suff er from depression and multiple suicide attempts in the past. He reported no drug allergies.Th e biopsy for tissue culture was negative for fungus, bacteria, and acid-fast bacilli. A plain radiograph displayed soft tissue swelling. Th e diagnosis of CRPS following trauma was made. Th e patient did not follow up in the dermatology department, and attempts to contact him were unsuccessful. Chart review showed that he attempted suicide several weeks later. DISCUSSIONCRPS is a condition that is aptly named, as it is often a complex entity to diagnose and manage. Th e disorder results from a neurologic dysfunction that produces severe and often debilitating pain. It most often aff ects extremities and may result from trauma or a vascular event. Th e condition has many pseudonyms, including refl ex sympathetic dystrophy, algodystrophy, causalgia, Sudeck's atrophy, transient osteoporosis, and acute atrophy of bone, which adds to the confusion. In 1993, a consensus group settled on CRPS as an umbr...
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