References and Further Reading 82 In general any lesion that is solid (echogenic) or partly solid should be investigated further generic brethine 2,5 mg otc. When there is a clear history of injury and a partly echogenic lesion is found generic brethine 5mg online, then it often may be fully assessed 5. However, this must only be performed with Introduction considerable caution as there are occasions where a malignant lesion haemorrhages, hiding the original The finding of a lump by a child or parent is always neoplasm. Although a good history and a definite diagnosis of haematoma from a single US examination can often go a long way in determin- examination. A haematoma, in the early phases, can ing whether a lesion needs further investigation, be solid and echogenic but it will liquefy over the next imaging can often completely reassure the patient few weeks and then resolve. This inevitable alteration and parents that the lesion is benign, permitting in pattern can be used to diagnostic advantage. Whilst soft tissue lowing such a lesion by additional US examination tumours in children are rarely malignant, it is can be invaluable—watching the “swelling” liquefy important to make an early diagnosis when they over a period of days or weeks until its resolution are! An area of injury that becomes “softer” and “smaller” is in keeping with a haematoma. A lump should never be labelled as a haematoma with- out confirmation of resolution by serial US examina- G. Allen, DCH, MRCP, FRCR The Royal Orthopaedic Hospital NHS Trust, Bristol Road tions, thereby avoiding the rare but significant risk South, Northfield, Birmingham, B31 2AP, UK of overlooking a malignant tumour with secondary 68 G. In addition, a lesion that is getting bination of clinical and US features. Any variation larger and “harder” is worrying whatever the imaging should be investigated with MR and biopsy. When resolution is not steady and progressive may help guide the biopsy as heterogeneous tissue it is prudent to perform MR and consider biopsy. On some occasions the US study prompts fur- Features that suggest that the region is more aggres- ther imaging. For example, if the adjacent bone is sive and therefore the best site for biopsy are a high involved or if the “lump” is uniformly solid in nature interstitial water content (where there is reduction and not likely to be a haematoma.

The absolute prevalence figures of persistent pain vary widely between cross-sectional studies and probably reflect differences in the time sample under consideration (e buy cheap brethine 5mg on-line. PAIN OVER THE LIFE SPAN 127 Nonetheless purchase brethine 5 mg otc, with one exception (Crook et al. These findings of reduced pain in very advanced age are perhaps surpris- ing given that disease prevalence and pain associated pathology continues to rise throughout the entire life span. If one examines pain at specific anatomical sites, a slightly different pic- ture emerges. The prevalence of articular joint pain more than doubles in adults over 65 years (Barberger-Gateau et al. Foot and leg pain have also been reported to increase with advancing age well into the ninth decade of life (Benvenuti, Ferrucci, Gural- nik, Gagnermi, & Baroni, 1995; Herr, Mobily, Wallace, & Chung, 1991; Leveille, Gurlanik, Ferrucci, Hirsch, Simonsick, & Hochberg, 1998). Studies of age- specific rates of back pain are more mixed with some reports of a progres- sive increase over the life span (Harkins et al. Another useful source of information on age differences in the pain expe- rience involves a review of symptom presentation in those clinical disease states that are known to have pain as a usual component. The majority of studies in this area focused on visceral pain complaints and particularly myocardial pain, abdominal pain associated with acute infection, and differ- ent forms of malignancy. Variations in the classic presentations of “crush- ing” myocardial pain in the chest, left arm, and jaw are known to be much more common in older adults. Remarkably, approximately 35–42% of adults over the age of 65 years experience apparently silent or painless heart at- tack (Konu, 1977; MacDonald, Baillie, & Williams, 1983). This represents a striking example of tissue damage without pain signaling the obvious threat, although the level of nociceptive input is seldom known with clinical 128 GIBSON AND CHAMBERS pain states. Nonetheless, attempts to address this issue by using more con- trolled and quantitative examples of cardiac pain have been recently under- taken. For many patients with coronary artery disease, strenuous physical exercise will induce myocardial ischemia as indexed by a 1-mm drop in the ST segment of the electrocardiogram. By comparing the onset and degree of exertion-induced ischemia with subjective pain report, it is possible to provide an experimentally controlled evaluation of myocardial pain across the adult life span.

The isolation of Streptococcus in the wound should be considered an exception to the former cheap brethine 5mg without prescription, since bacterial counts of less than 103 bacteria per gram of tissue can provoke invasive burn wound infection and should be treated buy generic brethine 5mg on-line. Great debate still exists regarding the appropriate isolation regimen for burn patients. For decades, burned patients were treated in dedicated burn centers with strict isolation techniques. It is now common knowledge, however, that burned patients do become infected from endogenous gram-negative flora. Cross-contamination among patients is minimal; therefore, the standard practice of strict isolation is no longer needed. In general, barrier nursing and hand washing after every patient contact should suffice to control infection in the burn unit. More strict measures need to be implemented with the appearance of multiple resistant organisms. Studies from several burn centers have laid to rest the idea that prophylactic antibiotics should be given to burn patients. It increases strains of multiple resistant organisms and challenges the posterior management of burn patients. It is advisable to administer antistreptococcal antibiotics in infants and small children for 24–48 h when sur- gery or application of synthetic dressing is considered. Children are often colo- nized by these organisms and are very sensitive to their growth. Perioperative systemic broad-spectrum antibiotics are advised when major surgery is per- formed. The manipulation of large burn wound surfaces produces a significant bacteremia and bacterial translocation in the digestive tract.