Rejected

The Analgesia Nociception Index (ANI) is a new method of identifying nociception-analgesia balance. In this study we investigate the correlation between the ANI/ numeric rating scale (NRS) values immediately before-after extubation. NRS values recorded in the post-anesthesia care unit, in a group of patients who underwent a laparoscopic cholecystectomy, with the aim to evaluate the potential use of ANI values in the prediction of postoperative pain levels.

Presentation A 55-year-old male patient with neuropathic bladder secondary to multiple sclerosis (MS) presented to the EmergencyDepartment (ED) with abdominal pain and no output from his suprapubic catheter (SPC) that was changed 24 hourspreviously. Diagnosis On examination, the SPC-tip was clearly visible at the external urethral meatus. Treatment The patient was managed by gently deflating the anchoring balloon, exchanging the SPC and a period of observationto ensure adequate catheter drainage. Conclusion Important learning points from this case are to observe urine draining after routine SPC change and to examine thegenitalia when a misplaced SPC is suspected.

We present 2 cases where the initial history and examination were similar to a Morton's/interdigital neuroma. In both cases, however, diagnostic ultrasound revealed symptomatic snapping of the proper digital nerve of the fifth toe. The anatomy of the proper digital nerve of the fifth toe may predispose it to a snapping phenomenon. Clinical awareness of this atypical cause of forefoot pain can help guide the diagnosis and treatment in those patients with persistent and refractory lateral forefoot pain and paresthesias.

Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years.

The use of opioids in chronic non-cancer pain (CNCP) has been a fast-rising treatment phenomenon in the last two decades. Though opioids are advocated in various chronic pain management guidelines, their use in chronic non-cancer pain still remains controversial as evidence of this approach is still weak. This paper highlights potential adverse effects associated with opioid use in pain management, including an increase in tolerance, dependence, and addiction outcomes. Nonetheless, opioids have an important place in contemporary CNCP management for selected patients. However, pain management must involve regular monitoring and the use of a multimodal pain management strategy. It is essential that the treating physician must be up-to-date with the form of therapy so that they have the requisite confidence to prescribe opioids and effectively manage adverse effects. Moreover, the adverse effects should be treated promptly to enhance patient compliance. Since this approach is beneficial for some patients, opioid treatment should only be applied on a case by case basis.

Ultrasonography is a commonly utilized tool in orthopedic surgery for the diagnosis and treatment of a variety of musculoskeletal conditions, including pathology about the wrist. Its value should not be underestimated when other diagnostic resources are unavailable – such as in a combat setting where ultrasounds, but not X-ray, are a standard equipment item. An active duty soldier presented to an orthopedic provider in an austere environment with chronic dorsal wrist pain due to a previous fall. Physical examination and dynamic ultrasound examination allowed the deployed provider to diagnose a scapholunate ligament injury. The patient was appropriately evacuated to a higher level of care without the need for X-ray or other advanced imaging modalities. Making this readily available resource a standard tool for providers deployed to a forward location could be beneficial for efficient and appropriate patient evacuation for musculoskeletal injuries. It can also rule out injuries that would otherwise have required unnecessary soldier movement through hostile territory for diagnostic tests such as X-rays. In addition, a simple technique and pearls for ultrasonography of the wrist are provided.

Shoulder injury related to vaccine administration (SIRVA) is defined as "shoulder pain with limited range of motion within 48 hours after vaccine receipt in individuals with no prior history of pain, inflammation, or dysfunction of the affected shoulder before vaccine administration." Corticosteroid injections (CSIs) have been proposed as a reasonable treatment modality for SIRVA, although evidence regarding efficacy is scanty. In this case series, we present two patients diagnosed with SIRVA who received CSI within 5 days of symptom onset and saw symptom resolution within 1 month. This is in comparison to a Centers for Disease Control and Prevention report that showed 65% of patients with SIRVA will have pain lasting longer than 1 month, and 25% will have pain lasting longer than 3 months. Our case series shows that CSIs may be an effective treatment modality for SIRVA. It would be reasonable to use CSIs as a first line treatment and should especially be considered in patients who have contraindications to nonsteroidal anti-inflammatory drugs.

Splenic disease are uncommon and primary tumors of the spleen are very rare. These are classified as splenic cyst, benign and malignant tumors. Splenic lymphangioma is a rare, slow-growing benign tumor of the spleen. More often seen in children, it is a congenital malformation of the lymphatic system and is rarely seen in adulthood. When present in adults, it is usually asymptomatic and would be incidentally detected through imaging studies. Infrequently, some patients would present with abdominal pain, distension, nausea, and may have palpable abdominal mass. It may be solitary or may have multiple splenic lesions.

To investigate the effects of dural puncture epidural technique for labor analgesia on mothers and neonates. From January to June 2019, one hundred healthy and nulliparous women, scheduled for elective labor analgesia in the Second Affiliated Hospital of Wenzhou Medical University, met inclusion criteriaand were recruitedin this prospective study. The inclusion criteria are as follows: American Society of Anesthesiologists physical statusⅠorⅡ, New York Heart Association gradeⅠorⅡ,150-175 cm in height,50-90 kg in weight and 37-45 weeks of gestation. They were randomly divided into epidural analgesia group(group P, 50)and dural puncture epidural group(group D, 50) by using random number table. Parturients in group D received epidural catheterization immediate after successful epidural puncture, while parturients in group P received a single dural puncture into subarachnoid space with a 27 gauge needle (successful puncture: outflow of cerebrospinal fluid) before epidural catheterization. Epidural labor analgesia was performed with epidural infusion of 0.1% ropivacaine plus 0.25 μg/ml sufentanil in both groups. The VAS scores were evaluated at the following time points: before epidural infusion, each uterine contraction within 30 min after infusion, 30 min, 60 min and 90 min after infusion and withdrawal of infusion. Labor process, mode of delivery, cases of increased oxytocin using, effective PCA pressings, sufentanil and ropivacaine dosages, complications of analgesia, neonatal status were recorded, as well. There were no significant differences in labor duration, mode of delivery, analgesia complications (nausea and vomiting, itching, headache after delivery and Bromage score for motor block), deceleration of fetal heart rate and neonatal Apgar score between the two groups (0.05). The number of effective PCA pressings, sufentanil dosage, ropivacaine dosage and cases of increased using of oxytocin were significantly more in group P(8.663,7.024,6.509,χ(2)=4.159,all 0.05), with (8.6±2.5) times, (29±4) μg,(105±15) mg,28% in group P, compared with (4.6±2.1) times,(23±4) μg,(88±12) mg,10% in group D, respectively. The first four VAS scores of uterine contraction after analgesia in group P(VAS=7.9±1.1,6.8± 0.9, 5.6±0.8, 4.5±0.8)were significantly higher than those in group D (VAS=6.8±0.7,4.7±0.8,3.5±0.8,2.9±0.7,5.966,12.332,13.125,10.643,all 0.05). The VAS scores at 90 min after analgesia and withdrawal of analgesia (VAS=2.7±0.6, 2.9±0.7) in group P were significantly higher than those in group D (VAS=2.4±0.6, 2.5±0.6, 2.500, 3.068, all 0.05). Compared with traditional epidural technique, dural puncture epidural technique can provide a rapid and effective analgesia with less analgesics, but without increasing adverse effects on mother and infant.