A rare case of spontaneous rupture of a branch of the uterine vein in a primigravida is discussed. The patient with an uncomplicated pregnancy presented with signs and symptoms suggestive of abruptio placenta with foetal distress. Lower segment Caesarean section was performed. The cause of acute pain was identified to be intra-abdominal bleeding secondary to the rupture of a branch of the uterine vein. The pathophysiology of the problem is discussed.
One hundred and eighty-three patients undergoing surgery were interviewed twenty-four hours following surgery to assess the quality of pain relief they received in the immediate postoperative period. Interviews were conducted using a standard questionnaire for all patients. They were asked to (1) rate the quality of pain relief they obtained on a Visual Pain Analogue Scale (VPAS-0 being no pain and 10 being the worst imaginable pain); (2) state whether they were happy and satisfied with the pain relief they received; (3) if dissatisfied, they were asked to give their reasons. 37.7% (69 patients) had moderate to severe pain--pain score greater than 6 on the VPAS. Most of these patients had undergone abdominal or major orthopaedic surgery. 32.7% (60 patients) were unhappy with their postoperative pain control. The main reasons for complaint from the patients were that analgesic injections were either not given promptly or were not given at all. The survey also highlighted the inadequate under-administration of narcotic injections in the postoperative period despite orders being written up. It showed there is an urgent need for setting up an Acute Pain Service for better postoperative pain control. An anaesthesiology based Acute Pain Service was started in October 1992.
An Acute Pain Service (APS) was started in University Hospital, Kuala Lumpur by the Department of Anaesthesiology in October 1992 for more effective control of postoperative pain. The main modalities of treatment included patient controlled analgesia (PCA) using morphine or pethidine with PCA devises, epidural opiate analgesia (EOA) using tramadol or fentanyl/bupivacaine mixture and subcutaneous administration of morphine or pethidine. Five hundred and fifty-one patients were managed in the first year, with an overall patient satisfaction score of 83%. The majority (98.5%) of them were after abdominal or major orthopaedic surgery. Eighty per cent of patients scored < 3 on the verbal numeric pain scale, where 0 is no pain and 10 is the worst imaginable pain, on the first postoperative day. Nausea and vomiting was an unpleasant side effect in 20% of patients.
Temporomandibular disorders are the commonest orofacila pain. Many of them present themselves to the primary care physician. A fundamental familiarity with this disorder is essential for proper diagnosis and management.
The failed back surgery syndrome (FBSS) is a difficult diagnostic problem both clinically and radiologically. Forty-three patients were evaluated prospectively with magnetic resonance imaging (MRI) and forty-five scans were obtained. Fifteen patients (33%) showed recurrent disc prolapse; 15 (33%) patients postoperative epidural fibrosis; 8 (18%) both recurrent disc prolapse and epidural scarring; 4 (9%) patients spinal stenosis, 2 whom also had both epidural fibrosis and recurrent disc prolapse; 2 (4%) normal scans; 2 (4%) patients arachnoiditis and 1 (2%) patient postoperative pseudomeningocoele formation. Gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA)-enhanced MRI was particularly helpful in differentiating recurrent disc prolapse and epidural fibrosis. Surgical findings in 11 patients were available. MRI correctly predicted recurrent disc prolapse in 6 patients, epidural fibrosis in 4 patients and spinal stenosis in 1 patient illustrating the value of this modality in the evaluation of FBSS.
Ten patients presenting with central chest pain and/or dysphagia were diagnosed to have oesophageal motility disorders (OMD) with an incoordinate motor function using computerised radionuclide oesophageal transit study (RT). The criteria for diagnosis of OMD with incoordination using RT were: an 'incoordinate' or 'to and fro' pattern characterised by multiple peaks of activity, prolonged total transit time or radionuclide bolus through entire length of oesophagus and a significant portion of bolus entering the stomach. These features are characteristic but not pathognomonic of diffuse oesophageal spasm (DES) as they are also seen in non-specific motility disorders (NSMD) and occasionally in order oesophageal motility disorders. Mechanical obstruction in the oesophagus and coronary artery disease were excluded appropriately in these patients. When manometry is not available, RT is a sensitive, safe, simple, rapid and non-invasive alternative modality in confirming certain oesophageal motility disorders.
This prospective survey attempt to study the incidence of post-operative back pain after lumbar epidural anesthesia for non-obstetric patterns and the correlation of this symptom with various contributing factors. One hundred and five patients who were given lumbar epidural anaesthesia as the sole anaesthesia for non-obstetric surgery were studied. The choice of equipment, number of attempts at giving the injection, duration of surgery and position of patient during surgery were documented. One week post-operatively, the patients were asked whether they recalled any back pain. The nature, duration and severity of the back pain was documented. Statistical analysis was achieved by using Chi-squared test. Twenty-eight patients recalled "injection site tenderness" post-operatively. The pain was mild to moderate in severity and lasted up to 4 days. None of the studied patients had post-operative "backache". The pain showed no significant correlation with needle size, technique of injection, use of epidural catheter, patient's position during surgery, duration and number of attempts made during epidural injection.
Matched MeSH terms: Back Pain/etiology; Back Pain/epidemiology*
Continuous spinal anaesthesia using the incremental technique was used in nineteen high risk patients with multiple medical problems, seventeen of whom were elderly, for lower limb orthopaedic and pelvic surgery. An intrathecal catheter (18G/28G) was inserted under local anaesthesia via the lumbar interspinous space. Spinal anaesthesia was induced with small incremental doses of 0.5% bupivacaine hydrochloride through the intrathecal catheter to achieve the level of analgesia required for surgery. The duration of surgery ranged from 45 to 300 minutes (mean + S.D 100 + 37 min). The initial volume of 0.5% bupivacaine required for surgery ranged from 0.8 ml-2.0 ml (1.2 + 0.7 ml) and the total volume ranged from 0.9 ml to 3.1 ml (mean + S.D 1.4 + 0.7 ml). Haemodynamic stability was well maintained perioperatively. Only two patients required 6 mg of ephedrine and 1 mg of aramine respectively for a greater than 25% reduction in systolic blood pressure with induction of spinal anaesthesia. Intrathecal morphine 0.1-0.3 mg was administered to 15 patients at the end of surgery for postoperative pain relief with good effect. One patient developed late respiratory depression from an inadvertent overdose of intrathecal morphine. No neurological sequelae were noted and no patient developed a postdural puncture headache. The use of the microcatheter was discontinued in the U.S.A and Australia following four case reports of cauda equina syndrome with this technique. Current opinion, however, is that the reported cauda equina syndrome was due to the neurotoxic effects of lignocaine 5% that was used and not due to the microcatheter per se. Continuous spinal anaesthesia is now used widely in Europe when cardiovascular stability is desired in poor risk patients undergoing lower limb and lower abdominal surgery.
A postal questionnaire concerning the Malaysian dentists' attitudes towards their patients yielded a 73.1% response rate. The results of this study indicated that a majority of dentists felt that patients had more negative than positive attributes. Private practitioners attributed more negative traits to their patients than their public sector colleaques. About 88% of dentists indicated that the most negative patient attribute was fear of pain. Fear of pain was perceived to be stronger than fear of the dentist (62.2%). likewise the patients' inability to seek treatment soon enough (78.4%), to come for regular check-up (72.7%) and to follow advice on personal oral hygiene(70.1%) were worrisome.
Acute abdominal pain during pregnancy presents a dilemma as signs and symptoms are often modified. Abdominal massage by traditional birth attendants (TBAs') during early labour is a common practice in the rural population, as it is perceived to give a soothening effect to the labouring mother. Many instances of abruptio placentae were reported in the past by this procedure, and in this case, the clinical picture presented as an abruptio placenta. Malpresentation and failure to progress were the indications for caesarean section despite the fetal demise. Severe post partum haemorrhage and failure to contract despite massive oxytocics resulted in the hysterectomy of the gravid horn, leaving the other horn intact.
PURPOSE: To determine if adequate anesthesia and akinesia could be obtained using an inferonasal quadrant sub-Tenons anaesthesia for cataract surgery.
METHODS: The sub-Tenons method of local anaesthesia was used in 50 patients undergoing extracapsular cataract extraction and lens implantation. The technique following was that described by JD Stevens in his study of 50 patients. Posterior sub-Tenons space was approached through a conjunctival incision in the inferonasal quadrant and the anaesthetic solution delivered by an irrigating cannula. The patients were assessed for residual ocular movements just before surgery. Effectiveness of anaesthesia was assessed during surgery using a verbal pain rating score. Scoring was based on the concept of a visual analogue pain score chart.
RESULTS: Total akinesia was obtained in 20% patients and total anaesthesia in 24% patients. The remainder of the patients had adequate akinesia and anaesthesia to proceed with and complete the surgery.
CONCLUSION: This method provides satisfactory anaesthesia for cataract surgery.
Records of 302 root-filled teeth treated by dental undergraduates were reviewed by four lecturers in the Department of Conservative Dentistry, University of Malaya. Preoperative and operative factors were evaluated for their association with postoperative pain experience of patients during the visit immediately after completion of biomechanical preparation. Eighty four percent of patients did not experience any pain after biomechanical preparation whilst the remaining 16 percent only complained of slight or moderate pain. The incidence of pain after biomechanical preparation is not high even when performed by inexperienced undergraduates. Teeth with a pre-existing painful condition had a higher chances of postoperative of pain. The incidence of postoperative pain was halved when teeth were associated with a sinus tract.
Three hundred and fifteen female workers with at least three months' employment history in a factory manufacturing disk drives were studied. Each worker completed a self-administered questionnaire on their personal particulars, hours of work, opinion on the work and the workplace and the presence and severity of aches/pains experienced over the past one month. One hundred and forty one (44.8%) of the workers had complaints of aches/pains. Of these, 81 (57.5%) reported an improvement in their symptoms during their off-days. 59 (41.8%) had symptoms affecting two or more sites. The most commonly affected sites were the hands and shoulders, followed by the head and back. There was no significant difference in the prevalence of symptoms between workers from the different work stations. Ninety four (66.7%) of these workers reported that the pains that were severe enough to affect their activities. 76 (53.9%) had to seek some form of medical treatment while 33 (23.4%) had to be on medical leave. However, the physical examinations of this group of workers were normal. The symptoms appeared to be influenced by their attitude towards work. A significantly higher number of workers with symptoms expressed dissatisfaction with work and had complaints of a noisy and cold environment. The study showed that workers' morale and the quality of the work environment may play an important role in improving their general well-being.
This review describes some of the mechanisms which are thought to be important in the causation of pain in chronic pancreatitis. Both medical and surgical techniques for treating this pain are described.
BACKGROUND/AIMS: Recently an increasing number of young colorectal carcinoma patients attending the University Hospital, Kuala Lumpur were noted. This report represents our experience with patients suffering from colorectal cancer aged 30 years or younger.
MATERIALS AND METHODS: All cases of primary carcinoma of the colon and rectum admitted to the University Hospital during 1990 to 1994 were respectively reviewed. Inclusion criteria was that the patient had been 30 years or younger. Data collected included age, gender, race, site of tumour, presenting symptomatology, duration of symptoms, histology, extension of tumour and nodal involvement predisposing factors, treatment and follow-up.
RESULTS: 21 patients were included, 5 patients (24%) were 30 years old at diagnosis, 12 (57%) patients were aged 20-29 years and 4 patients (19%) were less than 20 years old. Thirteen of the 21 patients were female, and 8 (38%) were male, 6 of the 21 patients (29%) were Malaysian, while 1 was Indian (4%). The remainder were Chinese, 14 patients (67%). Six patients (29%) had their primary tumour located in the rectosigmoid, 4 (19%) in the left colon, 1 (4%) in the splenic flexure, 2 in the transverse colon (9%), 1 in the hepatic flexure (4%) and 5 in the caecum 24(%). One patient had a tumour too diffuse to detect a primary site at the time of operation. One patient with a family history of polyps had his entire colon removed at age 14. He had 3 separate foci of tumour. The 5-year survival rate was 25%.
DISCUSSION: Most patients with extensive disease and mucinous histology. Lesions are commonly seen beyond the transverse colon (57%). Presentation included most commonly abdominal pain, haematochezia or haemoccult positive stools.
CONCLUSION: The symptoms above should alert surgeons to colorectal carcinoma as a differential diagnosis
A pilot study was conducted on 135 sixteen-year-old students from three rural schools in Kelantan to establish the prevalence of orofacial pain and discomfort. About 44% reported to have experienced some oro-facial pain in the preceding four weeks. About 27% of those with pain, still experienced the pain at the time of clinical examination but only 8% have consulted professional help. Most of the pain encountered were only mild or moderate in nature. Only 7% and 10% respectively, reported that the pain affected their sleep and concentration to study. The main cause was toothache and sensitivity. The prevalence of discomfort was 22%, the most common causes being recurrent oral ulcers and bleeding gums. The impacts of orofacial pain was mainly manifested at the personal level, and very few affecting social functioning. However, untreated decay and missing teeth were very low (mean DT 0.47, mean MT 0.27), while filled teeth (mean Ff 2.9) was the main component of the DMFf (mean 3.66, sd ± 2.6). Severe periodontal disease and the prevalence of traumatised teeth was not a major public health problem. The high prevalence of pain merit further research. Therefore a larger study involving other age-groups in other states is planned.
The construction of an electrical pain stimulator was described.
The parameters of pulse width and frequency on the quality of
pain stimulation was determined. The best design and construction
of the electrode for the stimulator was produced.
We report a rare case of undifferentiated (embryonal) sarcoma of the liver in a six-year-old girl who at presentation, had fever, right hypochondrium pain and hepatomegaly. The diagnosis was clinched by fine needle aspiration cytology and was subsequently reconfirmed by histopathological examination of the resected tumour. Pre-operative chemotherapy was given because primary resection was deemed not possible. The patient underwent a successful extensive hepatectomy followed by continuation chemotherapy
The presentation and management of psoas abscess was studied prospectively in 5 patients and retrospectively in 4. 3 patients had bilateral abscesses. All patients had back pain and a mass in loin or iliac fossa. 7 patients had no hip findings. One patient had a perinephric abscess and another had radiological features of tuberculosis of the spine. In the other seven no cause for the abscess could be identified. Ultrasonography demonstrated the abscess in all patients; CT scanning done in 5 patients was confirmatory. Drainage was done by an extraperitoneal route. Biopsy of the abscess wall in 2 patients demonstrated tuberculosis. They, the patient with TB spine and 3 others put empirically on anti-tuberculosis chemotherapy responded well. The perinephric abscess grew Pseudomonas sensitive to gentamycin, but she and two other patients died due to multiorgan failure.