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Pipe smokers 1 Squamous cell carcinoma: Usually located centrally have about 40% the risk of cigarette smokers discount 52.5 mg nicotinell with amex. Histologically squamous cell carcinoma bestos trusted 17.5mg nicotinell, nickel, chromium, iron oxides and coal gas shows a variety of patterns from well-differentiated le- plants. Pathophysiology 2 Small cell/oat cell/anaplastic lung cancer is a highly Lung cancer is characterised by multiple genetic alter- malignant tumour arising from bronchial epithelium, ations: but with properties of neuroendocrine cells contain- 1 In >90% of small cell lung cancers the p53 and rb tu- ing secretory granules. Tumours are centrally located mour suppressor genes are both mutated, and >50% and are associated with a rapid growth rate with and 20% respectively in non-small cell lung cancer. A proportion are thought to arise from pre- 3 Some of these genetic alterations are seen in pre- existing lung scars. It is the most common bronchial neoplastic lesions such as hyperplasia, dysplasia and carcinoma associated with asbestos and is propor- carcinoma-in-situ of the bronchial epithelium, but it tionallymorecommoninnon-smokers. Histologically appears that as many as 10 of these mutations are four patterns are seen: needed for the development of lung cancer. Clinical features r Solid carcinoma – poorly differentiated with mucin Cough or worsening of a pre-existing cough is the most production. These may exist as isolated pe- pain, or slowly resolving chest infection are all common. Cellsaretall,columnarandrelativelyuniform, Because of their pathological behaviour malignancies have few mitoses and secrete mucin (sometimes co- of the lung are divided into ‘small cell’ and ‘non-small pious). But up to 10 cm in diameter made up of cuboidal cells histologically, lung carcinoma is divided into four cell with hyperchromatic nuclei. The edge of the lesion appears typically fluffy or spiked, some may cause cavitation or collapse. It is mainly used to consolidation, pleural effusions, left recurrent laryn- assess the extent and spread, especially lymph nodes geal nerve palsy (hoarse voice), superior vena cava (see Table 3. Management 4 Neuromuscular: Neuropathy, myopathy, myositis, 1 Identification of histological type is essential. Surgical resection may be attempted ifestation of small cell carcinoma causing defective in limited alveolar cell carcinoma. It tends to occur more often in squamous cell and r tumour within a lobar bronchus or at least 2 cm distal adenocarcinoma). T1 N1 M0 Smaller than 3 cm distal to the carina with (N1) spread to ipsilateral hilar nodes. T2 N1 M0 Tumour larger than 3 cm, 2 cm distal to the carina invading the visceral pleura (T2), with spread to ipsilateral hilar nodes. Chapter 3: Respiratory oncology 137 r no involvement of the heart, great vessels, trachea, Clinical features oesophagus or vertebrae. The tumour can present with obstruction, recurrent r no malignant pleural effusion. Cells are cuboidal, arranged in a mosaic moval of the anatomical unit containing the tumour or trabecular pattern and have a dense core and neurose- (segment,lobeorlung)togetherwiththeassociatedlym- cretory granules. Complications 1 Lung collapse and consolidation distal to the obstruc- Prognosis tion. Median survival ∼8months with combi- r flushing of the face and neck sometimes leading to nation chemotherapy. Small cell carcinoma with metastases: Median survival ∼8months with Investigations combination chemotherapy, rarely survive to 2 years. Pathophysiology Prognosis These are highly vascular, low-grade malignant tumours 80% 10-year survival. These rarely cause the carcinoid syndrome, Definition as to do so they have to metastasise to the liver first (the Metastases to the lung are very common due to peptides are metabolised in the liver). In Secondary tumours nearly always develop in the lung lymphangitis carcinomatosa there is characteristically parenchyma where they cause little or no symptoms. Management Clinical features Truly single metastases can be removed surgically, but Usually asymptomatic, it is usually found as part of the this is uncommon. Rarely cause chest pain, haemoptysis or breathlessness (the last Prognosis suggests lymphangitis carcinomatosa). G astrointestinal system 4 Clinical, 139 Disorders of the stomach, 160 Disorders of the rectum and anus, Gastrointestinal infections, 148 Disorders of the small bowel and 172 Disorders of the abdominal wall, appendix, 163 Vascular disease of the bowel, 175 154 Disorders of the large bowel and Gastrointestinal oncology, 177 Disorders of the oesophagus, 156 inflammatory bowel disease, 167 r Pain arising from the hindgut, which continues to the Clinical dentate line, is felt in the suprapubic region. Pain may begin in one area, then become localised as the peritoneum overlying the organ is involved, e. Abdominal pain The causes of abdominal pain are diverse, frequently in- Radiation volving inflammation, ischaemia and/or obstruction in Pain radiating to the back is often due to retroperitoneal different organs. If The characteristics of abdominal pain should be the disease is sub-diaphragmatic, then pain can be re- clearlydefinedwhentakingahistory. Onset, character and timing Acute onset of pain suggests infarction, or an acute ob- Site struction of the biliary tree or urinary tract. The pain Well-localised pain suggests involvement of the parietal may then last for hours. The relation- abdominal pain is often ‘referred’ pain due to the pattern ship of pain to posture, meals (including the type of food of visceral innervation derived from the embryological and timing of onset related to eating) and the pattern of development. Constant pain may be burning, the opening of the common bile duct), the liver, pan- dull, sharp, mild or severe.

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Other sources buy discount nicotinell 52.5mg, however effective nicotinell 35mg, assert that ‘‘Trotula’’ did not exist and that the work attributed to her was written by a man. Any figure who could generate such diametrically opposed opinions about her work and her very existence must surely be a mystery. Yet the mys- tery of ‘‘Trotula’’ is inevitably bound up with the text ‘‘she’’ is alleged to have written. The Trotula (for the word was originally a title, not an author’s name) was indeed the most popular assembly of materials on women’s medicine from the late twelfth through the fifteenth centuries. Written in Latin and so able to circulate throughout western Europe where Latin served as the lingua franca of the educated elites, the Trotula had also by the fifteenth century been trans- lated into most of the western European vernacular languages, in which form it reached an even wider audience. The Latin Trotula was edited for publication only once, in the sixteenth century, under the title The Unique Book of Trotula on the Treatment of the Diseases of Women Before, Dur- ing, and After Birth,2 and the only modern translations available are based on this same Renaissance edition. The Renaissance editor, undoubtedly with the best of intentions, added what was to be the last of many layers of editorial ‘‘improvements. True, they were all probably of twelfth-century Salernitan origin, but they reflected the work of at least three authors with distinct perspectives on women’s diseases and cosmetic concerns. The first and third of these texts, On the Conditions of Women and On Women’s Cosmetics, were anonymous. The sec- ond, On Treatments for Women, was attributed even in the earliest manuscripts to a Salernitan woman healer named Trota (or Trocta). Each of the texts went through several stages of revision and each circulated independently through- out Europe through the end of the fifteenth century, when manuscript culture began to give way to the printed book. By the end of the twelfth century, an anonymous compiler had brought the three texts together into a single ensemble, slightly revising the wording, adding new material, and rearranging a few chapters. This ensemble was called the Summa que dicitur ‘‘Trotula’’ (The CompendiumWhich Is Called the ‘‘Tro- tula’’), forming the title Trotula (literally ‘‘little Trota’’ or perhaps ‘‘the abbre- viated Trota’’) out of the name associated with the middle text, On Treatments for Women. The appellation was perhaps intended to distinguish the ensemble from a general, much longer medical compilation, Practical Medicine, com- posed by the historical woman Trota. The Trotula ensemble soon became the leading work on women’s medicine, and it continued to be the object of ma- nipulation by subsequent medieval editors and scribes, most of whom under- stood ‘‘Trotula’’ not as a title but as an author’s name. He rewrote certain passages, suppressed some material and, in his most thorough editorial act, reorganized all the chapters so as to eliminate the text’s many redundancies and inconsis- tencies (due, we know now, to the fact that several authors were addressing the same topics differently). There is no way that a reader of this emended printed text could, without reference to the manuscripts, discern the presence of the three discrete component parts. Hence when some twenty years later a debate over the author’s gender and identity was initiated (and it has continued to the present day), it was assumed that there was only one author involved. What can they reveal about the impact of the new Arabic medicine that began to infiltrate Europe in the late eleventh century? Is there, in fact, a female author behind any of the texts and, if so, what can she tell us about medieval women’s own views of their bodies and the social circumstances of women’s healthcare either in Salerno or elsewhere in Europe? Answering these questions calls for close textual analysis that pulls apart, layer by layer, decades of accretion and alteration. Such analysis shows us not simply that there are three core texts at the heart of the Trotula but also that the ensemble became a magnet for bits and pieces of material from entirely unrelated sources. We cannot, for example, attribute the neonatal procedures described in ¶¶– to local southern Italian medical practices but must rec- ognize them instead as the work of a ninth-century Persian physician named Rhazes. Such analysis shows us, in other words, that the Trotula ensemble is a patchwork of sources. There is, consequently, no single (or simple) story to be told of ‘‘Trotula’’ or women’s medicine at Salerno. Knowledge of the multiplicity of the Trotula may resolve certain ques- tions (about the redundancies and inconsistencies that so troubled the Renais- sance editor Georg Kraut, for example), but it raises others. Particularly, if the texts are so protean (a total of fifteen different versions of the independent texts and the ensemble can be identified in the medieval manuscripts),8 howdowe choose any single version to study? Obviously, the authors of the three origi- nal, independent works had their own unique conceptions of the content and intended uses of their texts. On the basis of my reconstructions of these origi- nal forms of the texts, I describe in the Introduction their more distinctive medical theories and practices; I also summarize what is now known about the medical practices of the women of Salerno—including, most important, Trota. Nevertheless, the three original twelfth-century works often bore only an oblique resemblance to the text(s) that later medieval readers would have had in front of them. The Trotula ensemble, ragged patchwork though it is, has a historical importance in its own right, since it was this version of the texts that the largest proportion of medieval readers would have seen, and it was this assembly of theories and remedies (whatever their sources or however incon- xiv Preface gruous the combination originally may have been) that would have been most commonly understood throughout later medieval Europe as the authoritative Salernitan teachings on women and their diseases. One of the several versions of the ensemble was particularly stable in form and widespread in circulation: this is what I have called the ‘‘standardized en- semble,’’ which, with twenty-nine extant copies, ranks as the most popular ver- sion of the Salernitan texts in any form, circulating either independently or as a group. The standardized ensemble is a product of the mid-thirteenth cen- tury (whether it was produced at Salerno itself I cannot say) and it reflects the endpoint of what had been an active first century of development for the three texts. I have based the present edition on the earliest known complete copy of the standardized ensemble, an Italian manu- script from the second half of the thirteenth century, and I have collated it in full with eight other manuscripts coming from various parts of Europe and dating from the later thirteenth century through the turn of the fourteenth century.

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A sound understanding of problems educators and medical prac¬ basic mechanisms of disease areneces¬ pathophysiology is necessary to inter¬ titioners face in implementing the new sary but insufficient guides for clinical pret and apply the results of clinical re¬ paradigm nicotinell 17.5 mg mastercard. For instance order 17.5 mg nicotinell free shipping, most patients to treatment, which follow from basic whom we would like to generalize the The Former Paradigm in fact results of randomized trials for pathophysiologic principles, may would, The former paradigm was based on be incorrect, leading to inaccurate pre¬ one reason or another, not have been the following assumptions about the dictions about the performance of diag¬ enrolled in the most relevant study. The knowledge required to guide clinical nostic tests and the efficacy of treat¬ patient may be too old, be too sick, have practice. Italso follows that clinicians that suffering canbe ameliorated by the tional medical training and common must be ready to accept and live with caring and compassionate physician are Downloaded from www. These skills can be acquired garding the strength of evidence and Second, a program of more rigorous through careful observation of patients how it bears on the clinical problem. One of the areas eval¬ though, the need for systematic study results in a succinct fashion, emphasiz¬ uated is the extent to which attending and the limitations of the present evi¬ ing only the key points. The relevant adigm would call forusing the techniques ing pathophysiology and related ques¬ items from the evaluation form are re¬ ofbehavioral science to determine what tions of diagnosis and management, fol¬ produced in the Table. Third, because itis newto both teach¬ physicians22 and how physician and pa¬ The second part of the half-day is de¬ ersand learners, and because most clin¬ tient behavior affects the outcome of voted to the physical examination. Some of the concerning searching strategies The Internal Medicine Residency Pro¬ age of more than 3. Assessment of searching and crit¬ evidence-based the ical skills is Role Modeling teaching medicine, appraisal being incorporat¬ commitment is strongest in the Depart¬ ed into the evaluation of residents. We believe that the newparadigm siastic, effective role models forthe prac¬ cus on the Internal Medicine Residency will remain an academic mirage with tice ofevidence-based medicine (even in in ourdiscussion and briefly outline some little relation to the world ofday-to-day high-pressure clinical settings, such as of the strategies we are using in imple¬ clinical practice unless physicians-in- intensive care units). Acting as a At the beginning of each newacademic placed major emphasis on ensuring this role model involves specifying the year, the rules of evidence that relate to exposure. Department of Medicine faculty has can point to a number of large random¬ In subsequent sessions, the discussion been internists with training in clinical ized trials, rigorously reviewed and in¬ is built around a clinical case, and two epidemiology. These individuals have the cluded in a meta-analysis, which allows original articles that bear on the prob¬ skills and commitment to practice evi¬ one to say how many patients one must lem are presented. In other cases, responsible for critically appraising the program works toensurethey have clin- the best evidence may come from ac- Downloaded from www. The clinical teacher been evaluated in a patient sample that vide important insights. Diagnostic tests should make it clear to learners onwhat included anappropriate spectrum ofmild may differ in their accuracy depending basis decisions arebeing made. For instance: ease, plus individuals with different but expert in, for instance, diagnostic ultra¬ studies commonly confused disorders? The effectiveness and compli¬ of randomized trials of aspirin in this situa¬ Treatment. When care is taken to optimal and toxicity of low-dose, enteric-coated as¬ Review Articles. Teachers can out on an point solving must rely understanding particular courseof action would not be instances in which criteria can be vio¬ of More¬ underlying pathophysiology. Recognizing the limita¬ clinical teacher of evidence-based med¬ itis worth the effort to find out what the tions of intuition, experience, and un¬ icine must give considerable attention literature says on a topic. The likeliest derstanding of pathophysiology in to teaching the methods of history tak¬ per¬ candidate topics are common problems mitting strong inferences may be mis¬ ing and clinical examination, with par¬ where learners have been exposed to interpreted as rejecting these routes to ticular attention to which items have divergent opinions (and thus there is knowledge. Specific misinterpretations demonstrated validity and to strategies disagreement and/or uncertainty among ofevidence-based medicine and theircor¬ that enhance observer agreement. The clinical teacher should rections follow: keep these requirements in mind when 1. Difficulties we have encountered in ask all members ofthe group their opin¬ Correction. Many house staff start with rudi¬ appropriate for a critical appraisal ex¬ tuitive diagnosis, a talent for precise mentary critical appraisal skills and the ercise by asking the group the following observation, and excellent judgment in topic be threatening for them. It seems the group is uncertain Untested signs and symptoms should Cookbook medicine has its appeal. Do you feel it is important for usto be proved valid through rigorous test¬ efficient and distracting from the real sort out this question by going to the ing. The morethe experienced clinicians goal (to provide optimal care for pa¬ original literature? Most published crite¬ when clues to optimal diagnosis and duce critical appraisal, a senseoffutility ria can be overwhelming for the novice. Suggested criteria for studies of diagno¬ of clinical information in a systematic 4. The concepts of evidence-based sis, treatment, and review articles follow: and reproducible fashion.

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For persons formally trained in nursing technique this may represent a major mental obstacle to overcome buy 35 mg nicotinell free shipping. Lack of the tools and on-call resources that are routinely at our disposal in a modern cheap nicotinell 17.5 mg with mastercard, working healthcare system can be frustrating at best, and disabling if we dwell upon what we do not have versus what is available. In providing nursing care in the austere environment we need to focus on the patient first and foremost. The one overriding consideration that needs to be reinforced is this: model your care around that necessary for the comfort and recovery of your patient(s) and not around any medical-legal model of what care should be for a given case. Here we have tried to provide a brief answer to some of the common question coupled with more detailed references for those who are interested. It has gained a reputation as street drug and as a Vet anaesthetic, but is also widely used in human medicine, and is an ideal anaesthetic agent for austere situations. It produces a state known as “dissociative anaesthesia” – meaning it produces conditions suitable for performing painful procedures and operations while the patient appears to be in a semi-awake state although unresponsive. A side effect of this anaesthetic state is relative preservation of airway reflexes, respiratory effort, and a stable cardiovascular profile. It can be administered by intramuscular or intravenous injection or intravenous infusion. It is contraindicated in patients with an allergy to it (rare), and should be used with care in patients with psychiatric history, and patients with severe head injuries. Its main side effect is “emergence agitation” as the patient is waking up from the anaesthetic they may hallucinate and become agitated – this can be minimised by waking the patient up in quite dark environment, and can be treated with benzodiazepines (Valium). It also causes an increase in respiratory secretions and can cause transient increase in muscle tone. Due to its ease of use and lack of airway or respiratory suppression it is the ideal drug for use in an austere environment. It has been used extensively in the third world and has an excellent safety profile in comparison to other anaesthetic agent. In the following surgical procedures we will assume that the medic knows how to prepare a patient for surgery and set up a surgical field B. The primary objective in the treatment of soft tissue injuries is localisation or isolation of deleterious effects of the injury. To best accomplish this objective, remove all foreign substances and devitalised tissues and maintain an adequate blood supply to the injured part. Step one is a through debridement of the injured area, accomplished as soon as possible after the injury (when delay is unavoidable, systemic antibiotics should be started) The wound should be left open (with a few exceptions) to granulate. The wound must be kept clean during this time and antibiotics are usually indicated. The indication for delayed primary closure is the clean appearance of the wound during this time. Current military recommendations for antibiotic therapy for wounds is Cefotetan 2gm given every 12 hours >> 3. Muscles should be separated into there groups and each muscle group debrided separately. With colour being the least desirable - 171 - Survival and Austere Medicine: An Introduction Viable Dead or Dying Colour Bright reddish brown Dark, Cyanotic Consistency Springy Mushy Contractility Contracts when cut or pinched Does not contract Circulation Bleeds when cut Does not bleed 4. All devitalised muscle must be removed; if not the chance of infection is greater. It is better to take good muscle and have some deformity, than to leave devitalised muscle and have infection. The preferred method for debridement is to cut along one side of a muscle group in strips or blocks and not piecemeal a. Remove all blood clots, foreign material, and debris from the wound during exploration of the wound with a gloved finger. Vital structures like major blood vessels and nerves must be protected from damage. All foreign bodies must be removed, including small detached bone fragments, but time must no be wasted looking for elusive metallic fragments which would require more extensive dissection. Repeated irrigation of the wound with physiological salt solution during the operation will keep the wound clean and free of foreign material. When debridement is complete, all blood vessels, nerves, and tendons should be covered with soft tissue to protect from drying out. Dependent drainage of deep wounds must be employed << Place a Penrose drain (rubber tube) or wicking gauze into the wound>>. Liberal fasciotomy of an extremity is often an additional precaution that allows for post operative swelling.

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