Bimal H Ashar, M.B.A., M.D.

• Clinical Director, Division of General Internal Medicine
• Associate Professor of Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0013558/bimal-ashar

By sorting out the minor injuries arthritis lung cancer order naprosyn 500 mg without prescription, triage lessens the immediate burden on medical facilities arthritis pain wikipedia trusted 500 mg naprosyn. Priority First (I) Colour Red Medical need Immediate Clinical status Triage categories All methods of triage use simple criteria based on vital signs juvenile rheumatoid arthritis in feet cheap naprosyn 500mg mastercard. This is done on the basis of need so that resources can be allocated by good prioritisation arthritis shoes generic naprosyn 500 mg with amex. An adequate supply of essentials such as intravenous fluids arthritis neck pain cheap naprosyn express, dressings arthritis hip joint pain naprosyn 250 mg otc, pain medication, and oxygen must be arranged (see Chapter 30). Whether the traditional tented structure or the modular type housed in containers is employed, the facility must be equipped with radiograph capability, operating rooms, vital signs monitors, sterilising equipment, a blood bank, ventilators and basic laboratory facilities. Management in the field Field hospitals principally function in three main areas (Table 29. Field hospitals the decision to deploy field hospitals depends on the location, the number of casualties and the speed with which Summary box 29. This will include ensuring that the airway is secure, haemorrhage is under control and compartments are decompressed in the chest, skull, abdomen and the limbs. Examples First aid Emergency care for lifethreatening injuries Suturing cuts and lacerations, splinting simple fractures Endotracheal intubation, tracheotomy, relieving tension pneumothorax, stopping external haemorrhage, relieving an extradural haematoma, emergency thoracotomy/laparotomy for internal haemorrhage Debridement of contaminated wounds, reduction of fractures and dislocations, application of external fixators, vascular repairs Further Review at local hospital After damage control surgery, transfer patients to base hospitals once stable Initial care for non-lifethreatening injuries Transfer patients to base hospitals for definitive management developing into infection. A needle thoracocentesis will relieve a tension pneumothorax and a chest drain will be needed before a patient with a significant chest injury is transferred by air. Amputation for clearly devitalised limbs and gas gangrene should be undertaken at field hospitals as delay will be fatal. Specific aspects of care are discussed in the relevant chapters elsewhere in this book. Initial care for non-life-threatening injuries Many patients sustain serious injuries that require prolonged care. These include compound limb fractures, degloving injuries, dislocations of major joints, major facial injuries and complex hand injuries. These patients will need specialised care requiring transfer to the appropriate facility. Replantations of amputated limbs and other extensive procedures should not be attempted in field hospitals as they are time-consuming and divert resources and personnel to the treatment of a few patients. Debridement reduces the chances of anaerobic and necrotising infections and can prevent systemic sepsis. The following principles of debridement apply to all contaminated wounds: (a) After the administration of anaesthesia, the injured area is copiously irrigated with normal saline. Dirt and debris enmeshed in soft tissues can only be removed by excision of those tissues. Wounds with extensive cavitation should be enlarged longitudinally to gain better access and allow full decompression of the underlying muscles. This helps to visualise the damaged structures, and allow the surgeon to gain proximal and distal control of vascular injuries, and to identify severed ends of major nerves and tendons. Skin excision is kept to a minimum and only the margins of the wound need be trimmed back to healthy bleeding edges. Muscle that is pale or dark in colour, does not contract on pinching and does not bleed on cutting must be removed. In patients with traumatic amputations, the bone ends are tidied, the skin and muscle edges trimmed to the lowest level possible and the wound left open. In patients with associated fractures, skeletal stabilisation should be obtained before embarking on any repairs. In the case of loss of substance of the vessel wall, a vein patch or reversed vein graft may be employed. Silicone tubing may be used as a temporary bypass (stent) while vascular repair is being carried out in patients with critically compromised distal circulation. Nerves and tendons should not be dissected out nor should any attempt be made at definitive repair in wounds with tissue devitalisation, as this leads to poor results. The key structures should be identified and the edges trimmed and tagged with non-absorbable sutures to facilitate repair during subsequent exploration. Wounds sustained in disasters are heavily contaminated and are not suitable for primary closure. The wound is then covered with fluffed gauze and sterile cotton and the extremity splinted with a plaster of Paris slab. Tension should be avoided and one should not hesitate to use skin grafts to obtain cover. In wounds with gross infection no attempt at closure is made until infection is eradicated. These wounds are re-explored to make sure that there are no residual foreign bodies or devitalised tissue. Vacuum-assisted closure (VacPac) has emerged as a very useful tool for deeply cavitating wounds. The resources required for trauma patients are more than the typical case mix of a hospital. A rule of thumb is that only half the bed strength of a hospital can be utilised to provide optimum trauma care in an emergency situation. Hospital reorganisation In hospitals receiving mass casualties some reorganisation of services is unavoidable. This includes transferring patients with non-urgent conditions to other facilities, augmenting surgical services, reorganising the specialist rota and redesignating medical wards as surgical care areas. Internal organ damage is frequent and, unless immediate help is available, this accounts for the majority of early mortality figures. People trapped under fallen buildings may suffer crush injuries and crush syndrome if the duration is prolonged. Crush injuries and missile injuries cause extensive tissue damage and gross contamination, both favourable conditions for anaerobic and micro-aerophilic infections. Extensive tissue loss, neurovascular damage and loss of long fragments of bone are traditionally indications for amputation. This assumes that debridement and, if required, vascular repairs have been performed in a field medical facility. Facial injuries the management of facial injuries follows the same general principles of debridement and delayed closure as already outlined. Because of the functional and cosmetic importance of facial structures, skin and soft-tissue excisions are kept to a minimum. It enters the body through a wound and replicates, thriving on the anaerobic conditions present in devitalised tissues. It produces tetanospasmin, an exotoxin that binds to the neuromuscular junctions of the central nervous system neurones, rendering them incapable of neurotransmitter release. This leads to failure of inhibition of motor reflex responses to sensory stimulation and generalised contractions of agonist and antagonist muscles produce tetanic spasms. Spasms of the paravertebral and extensor limb musculature produce opisthotonus, an arching of the whole body. Laryngeal muscle spasm leads to apnoea and, if prolonged, to asphyxia and respiratory arrest. Wounds contaminated with soil can harbour tetanus spores, and active immunisation is indicated by administering 0. Reconstruction has been performed using a microvascular rectus abdominis flap covered with a skin graft. A thorough debridement followed by delayed primary closure has yielded good results. This includes a thorough wound debridement to eliminate the anaerobic environment. The wound should be closed using the delayed primary or secondary closure techniques. Diazepam is useful in preventing the onset of spasms but if these become sustained, the patient is paralysed, intubated and placed on a ventilator. The patient is then gradually weaned off the ventilator under cover of anticonvulsants. Necrotising fasciitis Necrotising fasciitisis is a rapidly spreading infection that produces necrosis of the subcutaneous tissues and overlying skin. It is caused by -haemolytic streptococci and, occasionally, Staphylococcus aureus but may take the form of a polymicrobial infection associated with other aerobic and anaerobic pathogens, including Bacteroides, Clostridium, Proteus, Pseudomonas and Klebsiella. The underlying pathology includes acute inflammatory infiltrate, extensive necrosis, oedema and thrombosis of the microvasculature. It spreads contiguously but occasionally produces skip lesions that later coalesce. Renal failure may occur as a result of hypovolaemia and cardiovascular collapse caused by septic shock. The rate of progression is dramatic and unless aggressively treated it leads to serious consequences with mortality approaching 70%. Creatinine kinase levels may show enormous elevation and biopsy of the fascial layers will confirm the diagnosis. Oxygen supplementation is beneficial and endotracheal intubation is required in patients unable to maintain their airway. High-dose penicillin G along with broad-spectrum antibiotics, such as third-generation cephalosporins and metronidazole, are given intravenously. The devitalised tissue is removed generously, going beyond the area of induration. In patients who survive, this results in a large wound, which will require skin grafting or flap coverage. Gas gangrene Gas gangrene is a dreaded consequence of late presenting missile wounds and crushing injuries. It is a rapidly progressive, potentially fatal condition characterised by widespread necrosis of the muscles and soft-tissue destruction. The common causative organism is Clostridium perfringens, a spore-forming, gram-positive saprophyte that flourishes in anaerobic conditions. Alpha-toxin, the most important, is a lecithinase, which destroys red and white blood cells, platelets, fibroblasts and muscle cells. The phi-toxin produces myocardial suppression while the kappa-toxin is responsible for the destruction of connective tissue and blood vessels. Devitalised tissue or premature wound closure provides the anaerobic conditions necessary for spore germination. A vicious cycle of tissue destruction is initiated by rapidly multiplying bacteria and locally and systemically acting exotoxins. The typical feature of this condition is the production of gas that spreads along the muscle planes. Systemically, the exotoxins causes severe haemolysis and, combined with the local effects, this leads to the rapid progression of the disease, hypotension, shock, acute kidney injury and acute respiratory distress syndrome. The characteristic sickly sweet odour and soft tissue crepitus appear with established infection but their absence does not exclude the diagnosis. These local signs are accompanied by pyrexia, tachycardia, tachypnoea and altered mental status. The diagnosis is made on the basis of history and clinical features: a peripheral blood smear may suggest haemolysis; a Gram stain of the exudate reveals large gram-positive bacilli without neutrophils; and the biochemical profile may show metabolic acidosis and renal failure. Radiography can visualise gas in the soft tissues and is particularly useful in patients with chest and abdominal involvement. High-dose penicillin G and clindamycin, along with third-generation cephalosporins, should be given intravenously. In established gas gangrene with systemic toxicity, amputation of the involved extremity is life saving and should not be delayed. No attempt is made at closure, amputation stumps are left open and the wound is lightly packed with saline-soaked gauze and then dressed. Crush injury and syndrome A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy or immobile objects. It is seen in earthquake and mining accident survivors and in battlefield casualties. Prolonged crushing of muscle leads to a reperfusion injury when the casualty is rescued. It also sequesters many litres of fluid, reducing the intravascular volume and resulting in renal vasoconstriction and ischaemia. Aggressive volume-loading of patients, preferably before extrication, is the best treatment. After provision of first aid and starting intravenous fluids the patient should be catheterised to measure urine output. A late fasciotomy, when it is obvious that the muscles of that compartment must be dead, is only likely to cause a massive release of myoglobin, as well as potentially introducing infection into dead tissue. It therefore best not to perform a fasciotomy in cases where entrapment has been for over 12 hours. The London Blitz is the name given to the German air raids on London between the 7th of September 1940 and the 17th of May 1941, during which it is estimated that more than 15 000 people were killed.

Even in patients with metastatic disease arthritis video purchase naprosyn with visa, tumour debulking can be considered to reduce the tumour burden and to control the catecholamine excess arthritis in neck and shoulder blade purchase naprosyn overnight. The natural history is highly variable with a 5-year survival rate of less than 50% arthritis in back of thigh discount naprosyn on line. Without adequate -blockade arthritis diet tea buy generic naprosyn 250mg on line, mother and unborn child are threatened by hypertensive crisis during delivery rheumatoid arthritis criteria order naprosyn in india. In the first and second trimesters the patient should be scheduled for laparoscopic adrenalectomy after adequate -blockade; the risk of a miscarriage during surgery is high arthritis in index fingers purchase naprosyn 500mg amex. In the third trimester, elective caesarean with delayed consecutive adrenalectomy 6 weeks later should be performed. Ganglioneuroma Definition A ganglioneuroma is a benign neoplasm that arises from neural crest tissue. Ganglioneuromas can occur in the adrenal medulla and are characterised by mature sympathetic ganglion cells and Schwann cells in a fibrous stroma. Neuroblastoma Definition A neuroblastoma is a malignant tumour that is derived from the sympathetic nervous system in the adrenal medulla (38%) or from any site along the sympathetic chain in the paravertebral sites of the abdomen (30%), chest (20%) and, rarely, the neck or pelvis. Clinical features Ganglioneuroma is found in all age groups but is more common before the age of 60. Ganglioneuromas occur anywhere along the paravertebral sympathetic plexus and in the adrenal medulla (30%). Pathology Neuroblastomas have a pale and grey surface, are encapsulated and show areas with calcification. They are characterised by the presence of immature cells derived from the neuroectoderm of the sympathetic nervous system. Treatment Treatment is by surgical excision, laparoscopic when adrenalectomy is indicated. Clinical features Predominantly newborn infants and young children (<5 years of age) are affected. Patients present with a mass in the abdomen, neck or chest, proptosis, bone pain, painless bluish skin metastases, weakness or paralysis. The more popular approach is the laparoscopic transperitoneal approach, which offers a better view of the adrenal region than open surgery. The advantage of the retroperitoneoscopic approach is the minimal dissection required by this extra-abdominal procedure. In the case of small, bilateral tumours or in patients with hereditary tumour syndromes a subtotal resection is warranted, to avoid steroid dependence. Treatment Prognosis can be predicted by the tumour stage and the age at diagnosis. High-risk patients receive high-dose multiagent chemotherapy followed by surgical Laparoscopic adrenalectomy Knowledge of the anatomy of the adrenal region is essential as anatomical landmarks guide the surgeon during operation. If these landmarks are respected, injury to the vena cava or renal vein, the pancreatic tail or the spleen can be avoided. To prevent tumour spillage, direct grasping of the adrenal tissue/tumour has to be avoided. This flap of peritoneum can then be used to retract the liver up and off the adrenal. Open adrenalectomy An open adrenalectomy is almost exclusively performed when a malignant adrenal tumour is suspected. On the left side the adrenal gland can be exposed after mobilisation of the splenic flexure of the colon, through the transverse mesocolon or through the gastrocolic ligament. A resection of regional lymph nodes is recommended in malignant adrenal tumours and should include resection of the tissue between the renal pedicle and the diaphragm. Left adrenalectomy With the patient positioned left side up, mobilisation of the spleen will displace it and the pancreatic tail medially. The resection is completed by mobilising the adrenal gland at the level of the periadrenal fat. Remove the gland in a bag and close the 3 port sites after infiltrating each with local anaesthesia. Retroperitoneoscopic adrenalectomy the first port is placed at the distal end of the 12th rib with the patient in the prone position. The right adrenal vein is covered by the retrocaval posterior aspect of the adrenal gland. The left adrenal vein is usually located at the medial inferior pole of the adrenal gland. High inflation pressures allow bloodless dissection, effectively tamponading the veins. Insulinomas of <2 cm in diameter without signs of vascular invasion or metastases are considered benign. Clinical features Insulinomas are characterised by fasting hypoglycaemia and neuroglycopenic symptoms. The episodic nature of the hypoglycaemic attacks is caused by intermittent insulin secretion by the tumour. This leads to central nervous system symptoms such as diplopia, blurred vision, confusion, abnormal behaviour and amnesia. The release of catecholamines produces symptoms such as sweating, weakness, hunger, tremor, nausea, anxiety and palpitations. Insulinomas have been diagnosed in all age groups, with the highest incidence found in the fourth to the sixth decades. A fasting test that may last for up to 72 hours is regarded as the most sensitive test. Usually, insulin, proinsulin, Cpeptide and blood glucose are measured in 1- to 2-hour intervals to demonstrate inappropriately high secretion of insulin in relation to blood glucose. About 80% of insulinomas are diagnosed by this test, most of them in the first 24 hours. Elevated C-peptide levels demonstrate the endogenous secretion of insulin and exclude factitious hypoglycaemia caused by insulin injection. Differential diagnosis the differential diagnosis of hypoglycaemia includes hormonal deficiencies, hepatic insufficiency, medication, drugs and enzyme defects. Occasionally, differentiating insulinoma from other causes of hypoglycaemia can be difficult. Nesidioblastosis is a rare disorder, mainly encountered in children, which is characterised by replacement of normal pancreatic islets by diffuse hyperplasia of islet cells. Virtually all insulinomas are located in the pancreas and tumours are equally distributed within the gland. Medical treatment of insulinoma Medical management is reserved only for patients who are unable or unwilling to undergo surgical treatment or for unresectable metastatic disease. Diazoxide suppresses insulin secretion by direct action on the beta cells and offers reasonably good control of hypoglycaemia in approximately 50% Prognosis and predictive factors No markers are available that reliably predict the biological behaviour of an insulinoma. When surgical options to treat malignant insulinomas cannot be applied, chemotherapeutic options include doxorubicin and streptozotocin. At open surgery an extended Kocher manoeuvre and mobilisation of the head and then the distal pancreas is performed to explore the whole gland. Tumours located deep in the body or tail of the pancreas and those in close proximity to the pancreatic duct require distal pancreatectomy. Postoperatively, blood sugar levels begin to rise in most patients within the first few hours after removal of the tumour. To preserve pancreatic function and reduce the risk of iatrogenic diabetes mellitus, patients in whom tumour localisation is not successful at operation should not undergo blind resection. Zollinger and Ellison described this condition in a joint paper in 1955 when they were both working at the Ohio State University. Unfortunately, the majority of patients have serum gastrin concentrations between 100 and 500 pg/mL and in these patients a secretin test should be performed. The secretin test is considered positive if an increase in serum gastrin of >200 pg/mL over the pretreatment value is obtained; this also rules out other causes of hypergastrinaemia. Pancreatic gastrinomas are mainly found in sporadic disease; most are found in the head of the pancreas. Other reasons for hypergastrinaemia are chronic atrophic gastritis, gastric outlet stenosis and retained antrum after gastric resection. Systemic chemotherapy is utilised in patients with diffuse metastatic gastrinomas. Streptozotocin in combination with 5-fluorouracil or doxorubicin is the first-line treatment. Prognosis and predictive factors In general, the progression of gastrinomas is relatively slow with a 5-year survival rate of 65% and a 10-year survival rate of 51%. Patients with pancreatic tumours have a worse prognosis than those with primary tumours in the duodenum. Therefore, it is nearly impossible to identify duodenal gastrinomas by preoperative imaging. In approximately one-third of patients the results of conventional imaging studies are negative. Rarely, tumours are situated in the body or tail and should be treated by enucleation or distal resection. Duodenal tumours smaller than 5 mm can Clinical and biochemical features Over 90% of patients with gastrinomas have peptic ulcer disease, often multiple or in unusual sites. Diarrhoea is another common symptom, caused by the large volume of gastric acid secretion. Differential diagnosis Differentiation from the more aggressive pancreatic adenocarcinoma is extremely important (Table 52. Medical treatment of non-functioning islet cell tumours When surgical excision is not possible, chemotherapeutic options include streptozotocin, octreotide and interferon. This may require partial pancreaticoduodenectomy as well as the synchronous or metachronous resection of liver metastases. Using an aggressive approach, curative resections are possible in up to 62% of cases and overall 5-year survival rates of around 65% can be achieved. Repeated resections for resectable recurrences or metastases are justified to improve survival. They are distributed throughout the pancreas with a head to body to tail ratio of 7:1:1. Overall 5- and 10-year survival rates of 65% and 49% respectively have been described. Clinical features Patients usually present late because of the lack of a clinical/ hormonal marker of tumour activity. Hypergastrinaemia may cause symptoms and the treatment of choice is Pathology Neuroendocrine cells can form hyperplasias or tumours. They can show different growth patterns, from benign tumours to high-grade undifferentiated carcinomas having a poor prognosis (neuroendocrine carcinomas). Types 3 and 4 are almost always malignant and surgical resection should be undertaken if possible. Chronic hypergastrinaemia is the result of chronic atrophic gastritis and achlorhydria, the alkaline pH being the stimulus for hypersecretion of gastrin. They do not cause symptoms and are usually detected during gastroscopy for other reasons. The pathogenesis, diagnosis and treatment of type 2 tumours is similar to that of type 1. Serum gastrin is normal; upper gastrointestinal bleeding is the usual symptom that leads to endoscopy. Type 3 tumours are usually larger than 2 cm and often have lymph node and liver metastases at the time of diagnosis. Gastrectomy and lymph node dissection and resection of liver metastases is the treatment of choice. Type 4 tumours present as large ulcerating malignancies similar to adenocarcinomas and should be treated accordingly. Clinical symptoms Symptoms that lead to the diagnosis are caused by either the primary tumour or its lymph node metastases. Acute or chronic, recurrent or persistent abdominal pain, ileus or, rarely, lower gastrointestinal bleeding may occur. About 60% of patients eventually develop cardiac symptoms because of stenosis and insufficiency of the pulmonary and, more rarely, the tricuspid valve, with enlargement and thickening of the wall of the right atrium. The aetiology is unknown but local effects of serotonin and kinins may contribute. Surgical procedure Surgery should be undertaken as soon as the diagnosis is made, even in the presence of liver metastases. The main goal is resection of the bowel primary tumour(s) and mesenteric lymph node metastases. In the presence of liver metastases, extrahepatic disease should be resected whenever possible. Metastatic disease in the mesenteric root will lead to long-term pain in the abdomen or back and to a poor quality of life, whereas liver metastases can be treated by chemotherapy or embolisation.

Generic 250mg naprosyn amex. Why do we get Gout or Arthritis.

Syndromes

• Tumors
• Adults: 300 to 1,040
• Nephrotic syndrome
• You will be asked to drink a liquid that contains glucose.
• Pheochromocytoma
• Systemic sclerosis (scleroderma)
• Nausea