CLINICAL NOTES AND CASE REPORTS SPLENOMEGALY (MALARIAL) WITH TORSION OF PEDICLE

Chief complaint: Severe abdominal pain and enlargement of the abdomen. Seven months ago, she had a short attack of epigastric pain associated with nausea, vomiting, chills and fever. At that time, she noticed enlargement of the abdomen. and this has steadily; increased to the present time. There have been occasional mild attacks of abdominal pain, but no severe ones until tw<> weeks ago. This came on rather suddenly, agonizing in character, and for three days practically continuous. An improvement was noted for three or four days, then more pam. Three davs before admission, another severe attack came, this time in the 10wer abdomen, associated with vomiting and fever. Bowels moved once daily.     

Acute pancreatitis complicated by spontaneous unilateral adrenal hemorrhage

A 52-year-old lady with a history of hypertension, dilated cardiomyopathy and diabetes mellitus type 2, presented with severe upper abdominal pain and vomiting of 4 hours duration. Acute pancreatitis was diagnosed based on high serum amylase and an abdominal computerized tomography scan. On the 3rd day she developed fever, increasing abdominal pain and shortness of breath. A repeated computerized tomography scan showed severe pancreatic necrosis and right adrenal hemorrhage.     

Obturator hernia

An elderly emaciated female patient presented with recurrent lower abdominal pain associated with nausea and vomiting due to obstruction of the small bowel. Although the Howship-Romberg sign and tender mass on digital rectal examination could not ascertained but plain X-ray abdomen shows features of acute intestinal obstruction. After resuscitation laparotomy was done and diagnosed as case of strangulated obturator hernia of Ricters type. Reduction of hernial content and resection of the gangrenous part of small bowel with end-to-end anastomosis done. The hernial defect is repaired by a proleine mesh. Abdomen closed in layers keeping a drain in right iliac fossa and pelvic cavity. The postoperative recovery was uneventful. Patient discharge with advice on 9th postoperative day.     

Spotted black snake (Pseudechis guttatus) envenoming

We report two cases of spotted black snake (Pseudechis guttatus) envenoming. One patient experienced localised burning pain around the bite and developed nausea, vomiting, diarrhoea, upper abdominal cramping and diaphoresis. He was treated with intravenous fluids and antiemetics, but no antivenom, and was discharged 23 hours after the bite. The second patient developed a severe headache, blurred vision and mild nausea, associated with severe pain and swelling of the bitten limb that took 4 days to resolve. No antivenom was given and the patient had no sequelae. Neither patient developed significant coagulopathy, myolysis or neuromuscular paralysis. Bites by this species appear to cause effects similar to those of the more common red-bellied black snake (P. porphyriacus).     

胰性脑病一例报道并文献复习

一例以＂突发剧烈上腹痛伴腹胀、恶心、呕吐4小时＂入院的男性患者,入院后诊断为：急性胰腺炎（重型）;胰腺假性囊肿;胰性脑病;低氧血症;代偿性呼吸性酸中毒。予禁食、胃肠减压、抑酸剂,生长抑素等减少消化液及胰液的分泌;抗生素,乌司他丁等抗感染及减少急性炎症反应;丹参改善胰腺微循环,中药（芍药承气汤）排毒及恢复肠功能等综合治疗,取得了满意的疗效。     

不同麻醉方式对老年患者全膝关节置换术围术期镇痛管理的影响

目的 观察两种麻醉方式对老年患者择期行首次全膝关节置换术（total knee arthroplasty,TKA）后疼痛及镇痛相关不良反应的影响。方法 收集2018年1月至2020年12月于复旦大学附属中山医院因膝关节骨性关节炎择期行TKA的老年患者（≥65岁）共计165例,其中单纯全麻76例（组1）,全麻复合股神经阻滞89例（组2）。记录术中阿片类药物用量。两组患者术后均予以48 h静脉自控镇痛（patient-controlled intravenous analgesia,PCIA）,术后第1天、第2天由专人随访相关情况,采用视觉模拟评分法（visual analogue scale,VAS）评估疼痛程度（包括静息状态和运动状态）,并记录镇痛相关不良反应（包括恶心呕吐、瘙痒、低血压、头晕、非正常停泵现象）。结果 组2术中阿片类药物用量低于组1(P=0.01)。组2患者术后第1天及第2天静息状态下疼痛评分高于组1(P=0.02,P=0.04),运动状态下疼痛评分无明显差异。术后第2天组2的头晕发生率低于组1(P=0.02),两组间其余不良反应（恶心、呕吐、瘙痒、低血压、停泵等）未见...     

Medullary infarction--was it depo-provera?

A possible relation between parenteral Depo-Provera and the subsequent development of medullary infarction in a heavy smoker is reported. The patient, a 40-year old Chinese woman had smoked 30 cigarettes daily for many years. She received injections of 150 mg Depo-Provera in April and July 1979. 2 days after the 2nd injection she was admitted to the hospital for vomiting and vertigo of 2 days duration. Clinical examination showed a 12th nerve palsy with the tongue deviated to the right but no other neurological abnormalities. She was treated symptomatically with intravenous fluids and stemetil and improved. On the 5th day her vertigo and vomiting progressed and she developed more lower brain stem signs. The same day she had a grand mal fit and went into a coma. She died on the 7th hospital day. A partial autopsy limited to the skull revealed minimal atherosclerosis of the vertebral artery but no thrombosis or occlusion. Cut sections after perfusion revealed an area of softening associated with some hemorrhage involving the whole length of the right half of the medulla oblongata dorsal to the olivary nucleus. Histological examination revealed an infarct undergoing liquefaction necrosis. The possibility of a causative relationship is suggested by the development of tinnitis about 12 hours after injection of Depo-Provera.     

Tubercular splenic abscess

Splenic abscess is a rare clinical condition and yet rarer is a tubercular splenic abscess. Here we report a case of tubercular splenic abscess. A forty years old male patient was admitted in Medicine unit of Mymensingh Medical College Hospital (MMCH) on 09-08-2006 with the complaints of Left upper quadrant abdominal pain and fever for 15 days and Respiratory difficulty for 2 days. Two days after admission he developed generalized abdominal pain and distension. Pain was not associated with vomiting. Patient was transferred to surgical unit for features of peritonitis. Ultrasonogram of whole abdomen revealed moderately enlarged spleen showing 8.8 x 9.7 cm semicystic mass, which may represent an abscess. There was mild free fluid collection in the lower abdomen. X-ray chest P/A view showed bilateral pleural effusion. On laparotomy huge amount of free pus was found in the peritoneal cavity and the spleen was hugely enlarged with a burst abscess cavity in it. Splenectomy and thorough peritoneal toileting was done. Postoperative recovery was uneventful except few stitch infections. Pus culture revealed no growth but histopathology of spleen confirmed Tubercular Splenic Abscess. Patient was given an antitubercular regimen with Rifampicin, Isoniazid, Ethambutol and Pyrazinamide for initial two month which to be followed by Rifampicin and Isoniazid for another ten months.     

Unilateral macular hemorrhage as the only presentation of megaloblastic anemia in pregnancy

A 22 year old unbooked female patient presented to our Prince Hashem Hospital in Al-Zarqa with labor pain. The patient was admitted to our labor room and delivered normally. Diagnosis of megaloblastic anemia was made after she developed left eye macular hemorrhage on the second day of delivery and confirmed by bone marrow biopsy.     

托烷司琼预防吗啡硬膜外自控镇痛引起恶心呕吐的效果观察

目的观察托烷司琼用于预防术后吗啡硬膜外自控镇痛（PCEA）引起恶心呕吐的效果。方法选择在腰麻与硬膜外联合麻醉下行开腹妇科手术患者120例,随机分成两组,每组60例。A组为托烷司琼4mg,B组为生理盐水4ml,分别加入PCEA药盒注入硬膜外间隙。术毕行吗啡PCEA镇痛,PCEA药液为吗啡8mg、0．75％左旋布卡因25ml。加生理盐水至100ml。观察两组术后48h内的镇痛效果及恶心呕吐的发生率。结果两组患者术后镇痛效果比较差异无统计学意义（P〉0．05）。两组患者术后48h内恶心呕吐发生率A组显著低于B组。恶心：A组7例（11．7％）B组16例（26．7％）;呕吐：A组3例（5．0％）B组19例（31.6％）（P％0．05或P％0．01）,差异有统计学意义。结论托烷司琼能够安全有效地减少硬膜外吗啡术后镇痛引起的恶心呕吐。     

Masculinizing granulosa cell tumour.

A 23-year-old woman had oligomenorrhea, underdevelopment of the breasts, moderate hirsutism and increased serum testosterone values associated with a benign noncystic granulosa cell tumour of the left ovary. She was frail, irritable and apathetic. Since the age of 7 she had had periodic abdominal pain with nausea, vomiting and dizziness; irritability and occipital headache appeared when she was older. Her symptoms resolved and the masculinization did not progress after the tumour was removed. Only six similar well documented cases have been reported.     

Severe hypercalcaemia four months after acute oliguric renal failure—successful treatment with intravenous clodronate

A 33 year old man developed acute oliguric failure lasting 66 days, eight days after admission with multiple gun shot wounds. On day 99 after admission, serum calcium was elevated mildly at 2.54 mmol/ 1 (normal range 2.1-2.5 mmol/1). Serum parathormone was undetectable. He was discharged soon afterwards. He presented again on day 164 with nausea, vomiting and blurred vision. Fundoscopy revealed an ischaemic retinopathy and extensive keratopathy. Serum calcium was 3.48 mmol/1 and serum creatinine 262 umol/l (normal range 40-110 umol/l). Repeat parathormone was undetectable and there was no evidence of myeloma, sarcoidosis or malignancy. Following treatment with intravenous saline and frusemide, serum calcium fell to a nadir of 3.05 mmol/ I. On day 168 an infusion of sodium clodronate 300 mg was given. Twenty-four hours later serum calcium was 2.65 mmol/l and 48 hours later calcium was 2.26 mmol/1. Normocalcaemia was maintained for 17 days and severe hypercalcaemia never recurred.     

delta 9-Tetrahydrocannabinol for refractory vomiting induced by cancer chemotherapy

Fifty-three patients receiving antineoplastic chemotherapy who had experienced severe nausea and vomiting refractory to standard antiemetic agents were treated with delta 9-tetrahydrocannabinol (THC). These patients were given THC 8 to 12 hours before, during, and for 24 hours after chemotherapy. Ten patients (19%) had no further nausea and vomiting; 28 (53%) had at least a 50% reduction of nausea and vomiting compared to previous courses with the same agents. No appreciable reduction of nausea and vomiting was seen in 15 patients (28%). Toxic reactions were generally mild, with only four patients experiencing reactions that necessitated stopping THC therapy. We suggest that, since THC is a useful antimetic agent in patients having refractory chemotherapy-induced vomiting, existing restrictions prohibiting its therapeutic use should promptly be eased.     

Evaluation of transcutaneous electroacupoint stimulation with the train-of-four mode for preventing nausea and vomiting after laparoscopic cholecystectomy

Objective： To evaluate the efficacy of transcutaneous electroacupoint stimulation with a train-of-four （TOF） mode for the prevention of postoperative nausea and vomiting （PONV） in the patients undergoing laparoscopic cholecystectomy. Methods： Ninety-six ASA Grade Ⅰ-Ⅱ patients scheduled for laparoscopic cholecystectomy were randomized into Neiguan （P6） electroacupoint stimulation group （treated group） and a placebo control group （placement of electrodes without electroacupoint stimulation）. The anesthetic regimen was standardized by needling at Neiguan on the left side and connecting the TOF peripheral nerve stimulator. The incidence of nausea, vomiting, severity, antiemetic dosage and the degree of pain were assessed at 0, 60, 120 min, and 24 h after surgery. Results： The incidence of nausea and vomiting, the dose of antiemetics and the occurrence of severe nausea were all significantly lower in the treated group compared with the control group and the score for pain was obviously reduced in patients of the treated group at 24 h post-operation （P〈0.05 or P〈0.01）. Conclusion： Transcutaneous electroacupoint stimulation at P6 with the TOF mode could reduce the incidence and severity of nausea and vomiting with analgesic effects.     

芬太尼透皮贴剂治疗1 664例老年癌痛的临床疗效分析

目的探讨老年癌症疼痛病人接受芬太尼透皮贴剂治疗的止痛疗效及安全性.方法全国23个省自治区、直辖市136家医院共1 664例,年龄≥65岁的老年癌痛病人接受了芬太尼透皮贴剂的止痛治疗,平均年龄72.6岁(65～90岁).芬太尼透皮贴剂的初始、15 d和30 d用药剂量均值分别为 31.34 μg/h,40.59 μg/h和47.50 μg/h (25～200 μg/h).结果治疗前疼痛程度评分为7.34.治疗1 d、3 d、6 d、9 d、15 d、30 d疼痛程度评分均值分别降低至3.82,2.80,2.43,2.11,1.83,1.79 (P<0.01),总有效率97.18%.治疗前25.4%的病人生活质量良好,治疗后15 d和30 d,71.15%和73.04%病人生活质量良好(P<0.01).不良反应便秘为10.70%,恶心为11.96%,头晕为6.85%,呕吐为3.85%,嗜睡为2.40%,呼吸抑制为0.12%.86.2%病人选择继续用芬太尼透皮贴剂.结论芬太尼透皮贴剂治疗老年癌痛病人安全有效,病人满意度高.推荐老年病人的初始剂量为25 μg/h.     

Paratubal cyst: a case report

Paratubal cyst can undergo torsion that can make it difficult to diagnose since tubal cysts mimic ovarian cysts. Most reported cases of paratubal cysts have occurred in pediatric patients, and this type of cyst rarely causes symptoms of lower abdominal pain mimicking appendicitis. We present the case of a 28-year-old female who was taking Carbergoline for hyperprolactinoma associated with a pituitary adenoma who came to the ER at Henry Ford Hospital in Detroit experiencing severe abdominal pain. Her pain was not accompanied by nausea, vomiting or other gastrointestinal symptoms. A transvaginal ultrasound revealed a normal uterus with the right ovary containing a cyst measuring 3 cm. x 2 cm. She was released on analgesics and seen at the clinic at Henry Ford Hospital three days later. She was still experiencing pain and was given antibiotics and Darvocet. When the pain had not subsided 48 hours later, a decision was made to perform diagnostic laparoscopy. Surgery was performed 10 days later and a paratubal cyst was removed that was twisted twice on its pedicle. This case illustrates the fact that torsion of paratubal cyst should be included in the differential diagnosis of adnexal pain.     

多瑞吉对中重度晚期肝癌疼痛早期缓解效果的研究

目的研究多瑞吉（芬太尼透皮贴剂）对中重度晚期肝癌癌痛的早期镇痛效果及安全性。方法选择具有中重度癌痛的晚期肝癌患者40例,随机分为多瑞吉治疗组和安慰贴对照组,观察记录用药后第1天（3h,6h,9h,12h,24h）的疼痛强度、重要生命体征、生活质量评分和不良反应。结果多瑞吉治疗组中除2例患者因用药后出现严重的恶心、呕吐不能耐受而停药外,至用药后24h中度疼痛组缓解有效率为81.8%,重度疼痛组为88.9%,两组比较无显著性差异（P〉0.05）。患者早期生活质量改善明显,较治疗前有显著性差异（P〈0.05）,安慰贴对照组治疗前后疼痛感缓解不明显（P〉0.05）。多瑞吉治疗早期不良反应以恶心、呕吐、头晕为主,发生率较低,多数患者经对症处理后可缓解,未见呼吸抑制、成瘾发生。结论芬太尼透皮贴剂治疗晚期肝癌疼痛,镇痛效果显著而稳定,使用安全方便。治疗过程中应加强对早期不良反应的观察及处理,可避免严重并发症的发生,有效改善患者的生活质量。     

Control of severe pain with sustained-release morphine tablets v. oral morphine solution.

Recently a sustained-release morphine sulfate tablet (MS Contin [MSC]) was introduced in Canada. In a randomized double-blind crossover trial we compared MSC given every 12 hours with a morphine sulfate solution (MSS) given every 4 hours to 17 patients suffering from chronic severe pain. After titration of the morphine dosage to optimize the analgesic effect, each patient received 10 days of therapy with either MSC or MSS, then 10 days of therapy with an equal daily dose of the other formulation. Both preparations provided effective pain control, with minimal side effects. There was no significant difference between MSC and MSS in pain scores on a visual analogue scale (VAS), severity scores for tiredness and nausea, amount of supplemental morphine needed for break-through pain or patient preference. The plasma morphine concentrations tended to be greater during treatment with MSC. The study had an 89% probability of detecting a clinically significant difference in VAS pain scores. We conclude that an individualized, twice-daily regimen of MSC is as effective as MSS given every 4 hours for control of severe pain. The twice-daily regimen has several advantages: it provides for an uninterrupted night's sleep, it is substantially more convenient than the six doses per day required with MSS, and it should help reduce both medication errors and noncompliance.     

曲马多和吗啡用于术后PCIA的观察与比较

目的通过对开胸术后剧痛病人行曲马多病人自控镇痛(patient controlled intravenous analgesia,PCIA)并与吗啡PCIA比较,评定曲马多对病人镇痛程度和恶心、呕吐等不良反应的发生率以及在呼吸系统和心血管系统方面的安全性.方法择期开胸手术病人60例随机分为曲马多组和吗啡组,每组30例,两组病人全麻诱导术中麻醉维持用药相同,术毕清醒拔管后与外周输液静脉连接PCA泵.镇痛治疗时间48h.PCIA选择负荷剂量 维持剂量 PCIA给药模式.术后4,8,12,24和48h随访并记录BP,P,R及药物用量、疼痛评分、恶心呕吐、皮肤骚痒等情况.结果两组镇痛效果无显著性差异;曲马多组不良反应低于吗啡组.结论曲马多用于术后PCIA与传统的吗啡相比:镇痛效果较好,曲马多用于术后PCIA是一种有效、安全的方法.     

小剂量硫酸镁复合芬太尼术后静脉镇痛

目的比较小剂量硫酸镁联合芬太尼与单纯芬太尼术后静脉镇痛的临床效应。方法选择行上腹部手术后患者90例,随机均分为三组,每组30例,以一次性静脉镇痛泵（2ml／h）分别行静脉术后镇痛,F组：单纯芬太尼镇痛,0．2μg／（kg·h）芬太尼＋5mg氟哌利多,MF1组：硫酸镁联合芬太尼镇痛,0．2μg／（kg·h）芬太尼＋0．5mg／（kg·h）硫酸镁＋5mg氟哌利多,MF2组：硫酸镁联合芬太尼镇痛,0．2μg／（kg·h）芬太尼＋1mg／（kg·h）硫酸镁＋5mg氟哌利多,各组镇痛泵中药物均用医用盐水稀释至100ml,观察各组患者镇痛48h内的静息镇痛评分（VAS方法）,恶心呕吐,皮肤瘙痒和尿潴留的发生情况。结果三组患者的静息镇痛评分在12h内MF1组和MF2组明显低于F组（P〈0．05）,而在12h后没有明显差别（P〉0．05）;恶心呕吐,皮肤瘙痒和尿潴留发生率MF1组和MF2组显著低于F组（P〈0．01）。MF1组和MF2组之间在静息镇痛评分和并发症发生方面没有明显差别。结论小剂量硫酸镁用于术后静脉镇痛可明显减少芬太尼的剂量,使恶心呕吐,皮肤瘙痒和尿潴留发生率降低,镇痛效果明显优于单纯芬太尼术后静脉镇痛。