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We included outpatient musculoskeletal is anticipated that order aurogra 100mg with amex, after a decade 100mg aurogra overnight delivery, trainee experts who meet interna- practices in the southeastern United States buy aurogra 100mg visa, specifcally covering tional standards will build a locally led fully developed residency the states of Georgia, Alabama, Florida, and South Carolina. African governments also need to understand the societal pitals and inpatient services were excluded, as was the purchase of cost of disability and invest in rehabilitation by training rehabilita- used ultrasound devices. Data was collected from the practices on tion team members as well as building more facilities. Ghana, the whether they had received manufacturer training, loaned a device, black star of Africa, has set the pace. Results: Fifty-two outpatient musculoskeletal practices purchased 56 new ultrasound devices during the time period. Fifteen devices (25%) were bought by practices where the physicians had no prior training with 967 ultrasound nor loaned a device before purchase. Residents will learn to work effectively with other as legitimate in order for governments to fund education and de- clinicians to improve the quality of care, health care delivery, learn ploy trained physicians into rehabilitation practice. After a decade about cost-effective care, recognize system error and advocate for of research and experimentation the International Rehabilitation system improvement, learn how to monitor transitions of care, pro- Forum and Komfo Anokye Teaching Hospital in Kumasi, Ghana, viding Effective Handoffs and Safe Discharge Planning. Methods: The team devel- prepare future physicians to be stewards of safe, high quality, high oped a 1-year fellowship for family medicine or internal medicine value, patient centered care and develop a culture of safety and specialists. Journals demonstrate compliance with guidelines by requir- ing authors to register trials before enrolling patients. Reporting guidelines are structured out- tation, Shanghai, China lines for authors to use when describing their methods. There is no review of prospective studies broad range of publications, including those focused on physical that systematically examined the relationship between sedentary therapy, occupational therapy, rehabilitation nursing, speech pathol- behaviors and boenhealth outcomes among graduate students. Trial registration be- cross-sectional study aimed to look for an association in between gan Jan 1, 2016. Material and Methods: editors, authors, and reviewers on how best to apply these guidelines. No gender monly used words that support communication and language learn- differences were found. This review physical activity and sedentary behavior infuence whole body bone aims to evaluate, summarize, and synthesize the data on Malay mass body composition. Frontera4 summarized following its frequency of occurrence, word common- 1 ality and part-of-speech. For statistical analysis, we used the Wilcoxon 971 test and the Mann-Whitney test. As such a long examination session is not practical, it acquisition of knowledge and skills. Participants were assigned alternating 973 roles of hemiplegic individuals, caregivers and heath care providers. Focus domains 1Hospital Rehabilitasi Cheras, Department of Rehabilitation Medi- in the course were hemiplegic shoulder care, transfers, mobility and cine, Cheras, Malaysia activities of daily living. Course survey, pre and post-tests were performed to measure the partici- Introduction/Background: Since the start of Cheras Rehabilitation pants’ level of understanding and overall response. Results: A to- Hospital’s Paediatric Rehabilitation Service in year 2013, many ac- tal of 80 participants enrolled in the course. Majority (80%) of the tivities were conducted for both in- and outpatient to improve the course participants were from the nursing units. One of the annual and post-test questionnaires showed overall increased percentage of activities carried out is the hospital based school holiday programme, level of understanding of hemiplegic care. The programme aims to provide short increased confdence in their practical skills. Incorporating role-play to improve their fne and gross motor skills, mobility and activities as an adjunct to interactive lectures and hands-on demonstration ses- of daily living; also to improve their motivation, behaviour and so- sion was highly evaluated by participants to be an effective learn- cial interaction skills. Conclusion: Experiential Learning is an effective tool with specifc theme was conducted. Hirano2 caregivers agreed that their children learned many skills and more 1Fujita Health University, Occupational Therapy, Toyoake- Aichi, independent after the programme. They felt that the programme was Japan, 2International University of Health and Welfare, Occupa- excellent and would recommend it to other parents. NeuroSpinal Hospital which is private to make the proper database of our patients and their caregivers. It tertiary highly specialized Neuro&Spine surgical referral center af- will lead us to clasify their pattern in the purpose of giving the best ford from A-Z comprehensive (surgical & conservative) manage- rehabilitation approach, including educational program. The highest level of education of parents were School of Business and Leadership, Durban, South Africa college graduate but only in a minor amounts (4. Most of parents were senior high school graduate, Introduction/Background: Globalisation brings new opportunities 37. A followed by speech delay (13%) and global delayed development survival tactic is to have a healthy, engaged and highly produc- (10. Healthy employees are vital to assist in functioning Conclusion: Pediatric patients who came to physical medicine and and competing in the global business environment. Material and Methods: The need to give the suitable educational rehabilitation program to be fol- aim of this study was to understand employees’ awareness, atti- lowed easily by the parents at the hospital and home setting. A probability sample of 301 employees was drawn from a population of 1,314 employees. A further recommendation is that times when services are Dubai, United Arab Emirates offered should be extended. Hope for further re- Frontières, Trauma, Brussels, Belgium, 3Médecins Sans Frontières, covery was the greatest perceived barrier to community reintegra- Trauma, Luxembourg, Luxembourg tion. So practitioner account for prognosis exactly and counsel the length Introduction/Background: Considering the needs and benefts for of hospital stay early. Within those centers, physiotherapists are 1National Rehabilitation Hospital, Rehabilitation, Yangon, Myan- part of a multidisciplinary team, which also comprises surgeons, mar Burma medical doctors,nurses, mental health counsellors and hygiene promotion professionals, in the common objective to offer the best Introduction/Background: Objectives of this study are to describe possible care for the trauma patients and optimize their recovery. It is a tertiary level teaching hospital scores for patients with upper limb and lower limb trauma, admit- and 50 bedded hospital. Multiple needs of the end of both in-and outpatient-based physiotherapy were collect- disable person could be met by multi-disciplinary team approach. Material score improved from 32 to 34 (6%) for inpatients and from 43 to and Methods: P&O workshop provides various types of Prosthesis 49 (14%), or up to almost complete regain of functionality, for out- and there are three phases of amputee management. In 2012, total amputees are 237, 366 score was observed for inpatients and outpatients respectively, and amputees in 2014 and in 2015, there are 556 amputees. Most of a functional recovery of 16% and 29% (up to a mean score of them are males and between 20 to 50 years. Associations with the cause of trauma and with congenital and acquired such as occupational accidents, mine in- different interventions were also observed. Conclusion: A marked juries, road traffc accidents, diabetes mellitus, peripheral vascular success of the physiotherapy in these resource-poor, violent set- diseases and malignancies. Results: The workload of P&O work- tings was noted for both pain reductionand functionalrecovery in shop is increasing year by year because of more and more injuries. Mapping of the associations There are only 10 P&O technicians in Myanmar and P&O services between patient characteristicsand functional evolution/outcomes are available at National Rehabilitation Hospital, Defense Services will allow tailoring of the physical rehabilitation protocols. So, ulations and protocols, and to assess the validity and sensitivity of our visions are to do the mobile team services for P&O application the different scoring systems. Rahman1 Medicine, Seoul, Republic of Korea 1Bangabandhu Sheikh Mujib Medical University, Physical Medi- cine and Rehabilitation, Dhaka, Bangladesh Introduction/Background: To ascertain the factors infuencing community reintegration of patients with acquired disabilities Introduction/Background: Disasters result in signifcant numbers who were given rehabilitation in post-acute rehabilitation center of disabling impairments. Material and Methods: A sample of 96 individu- Floods and cyclones killed millions of people in Bay of Bengal dur- als with acquired disabilities who admitted to National rehabilita- ing last centuries. Non-compliant building collapse had times follow-up survey by telephone interview and retrospective major casualties during recent past. Inadequate preparedness and insuffcient ily member care-giver and better functional state had signifcantly equipment for rescue are major causes of death and disability. Among the reason review intends to emphasize the need of health related rehabilitation for prolonged hospitalization, hope for further recovery was of disaster victims at low resource setting in Bangladesh. Conclusion: and Methods: We have gone through the recent events of natural dis- Family member care-giver has a positive impact on reintegration.

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Third-generation cephalosporins are sensitive to another class of b-lactamase discount aurogra 100mg line, the cephalosporinases (genes are generally located on chromosomes as opposed to plasmids) buy aurogra 100 mg fast delivery. They are used in treatment of streptococcal infections as well as infections Chapter 11 Drugs Used in Treatment of Infectious Diseases 257 caused by E generic aurogra 100mg fast delivery. Ceftriaxone is used for sexually trans- mitted infections caused by gonorrhea, as well as in empiric therapy for commu- nity-acquired meningitis. Adverse effects and drug interactions (1) Cephalosporins most commonly cause hypersensitivity reactions (2%–5%); 5%–10% of penicillin-sensitive persons are also hypersensitive to cephalosporins. Aztreonam (Azactam) (1) Aztreonam is a naturally occurring monobactam lacking the thiazolidine ring that is highly resistant to b-lactamases. Vancomycin (Vancocin, Vancoled) (1) Vancomycin is a tricyclic glycopeptide that binds to the terminal end of growing pepti- doglycan to prevent further elongation and cross-linking; this results in decreased cell membrane activity and increased cell lysis. Rapid infusion may cause anaphylactoid reactions and ‘‘red neck’’ syndrome (flushing caused by release of histamine). Bacitracin (1) Bacitracin inhibits dephosphorylation and reuse of the phospholipid required for accep- tance of N-acetylmuramic acid pentapeptide, the building block of the peptidoglycan complex. Cycloserine (Seromycin) (1) Cycloserine is an amino acid analogue that inhibits alanine racemase and the incorpo- ration of alanine into the peptidoglycan pentapeptide. Daptomycin (Cubicin) (1) Daptomycin is a bactericidal agent that binds to and depolarizes the cell membrane resulting in loss of membrane potential and rapid cell death. Fosfomycin (Monural) (1) Fosfomycin inhibits the enzyme enolpyruvate transferase and therby interferes down- stream with the formation of bacterial cell wall specific N-acetylmuramic acid. Structure and mechanism of action (1) Aminoglycosides are amino sugars in glycosidic linkage to a hexoseaminocyclitol. Transport across the inner membrane requires active uptake that is dependent on electron transport (gram- negative aerobes only), the so-called energy dependent phase I transport. This ‘‘freezes’’ the initiation complex and leads to a buildup of monosomes; it also causes translation errors. Selected drugs and their therapeutic uses (1) The role for aminoglycosides has decreased substantially due to their narrow spectrum of activity and toxicity, and the availability of other agents. Adverse effects (1) Aminoglycosides have a narrow therapeutic index; it may be necessary to monitor se- rum concentrations and individualize the dose. Tetracyclines (tetracycline [Sumycin], oxytetracycline [Terramycin], demeclocycline [Declo- mycin], doxycycline [Vibramycin], minocycline [Minocin], tigecycline [Tygacil]) a. Structure and mechanism of action (1) Tetracyclines are derivatives of naphthacene carboxamide. Resistance to one tetracycline confers resistance to some, but not all, congeners. Doxycycline is excreted almost entirely via bile into the feces and hence is the safest tetracycline to administer to individuals with impaired renal function. Spectrum and therapeutic uses (1) Tetracyclines are active against both gram-negative and gram-positive organisms, but the use of these agents is declining because of increased resistance and the develop- ment of safer drugs. They are also used in combination regimens for elimination of infections caused by Helicobacter pylori. Chapter 11 Drugs Used in Treatment of Infectious Diseases 261 (4) Tigecycline, a derivative of minocycline, has a broad spectrum of activity and has activ- ity against many tetracycline-resistant organisms. Children age 6 months to 5 years receiving tetracycline therapy can develop tooth discolorations. Pharmacologic properties (1) Chloramphenicol is absorbed rapidly and distributed throughout body fluids. Therapeutic uses (1) Chloramphenicol is a broad-spectrum antibiotic used to treat most gram-negative organisms, many anaerobes, clostridia, chlamydia, mycoplasma, and rickettsia. How- ever, because of the potential for severe and sometimes fatal adverse effects, use of this agent is limited to the treatment of infections that cannot be treated with other drugs; these infections include typhoid fever (although resistance is increasingly a problem), meningitis due to H. Adverse effects (1) Chloramphenicol causes dose-related bone marrow suppression, resulting in pancyto- penia that may lead to irreversible aplastic anemia. Also, chloramphenicol causes hemolytic anemia in patients with low levels of glucose 6-phosphate dehydrogenase. This syn- drome results from the inadequacy of both cytochrome P-450 and glucuronic acid con- jugation systems to detoxify the drug. Elevated plasma chloramphenicol levels cause a shocklike syndrome and a reduction in peripheral circulation; the incidence of fatalities is high (40%). Erythromycin, clarithromycin (Biaxin), azithromycin (Zithromax), telithromycin (Ketek) a. It is due primarily to increased active efflux or ribosomal protection by increased methylase production. Pharmacologic properties (1) Erythromycin is inactivated by stomach acid and is therefore administered as an enteric-coated tablet. Use of clindamycin is limited to alternative therapy for abscesses associated with infections caused by anaerobes, such as B. It is used in dental patients with valvular heart dis- ease for prophylaxis of endocarditis. Potential severe pseudomembranous colitis occurs as a result of superinfection by resistant clostridia. Sulfonamides: sulfadoxine/pyrimethamine (Fansidar), sulfisoxazole, sulfadiazine, silver sulfa- diazine (Silvadene), sulfasalazine (Azaline, Azulfidine), trimethoprim (Proloprim), and trime- thoprim/sulfamethoxazole (Bactrim, Septra) a. Spectrum and therapeutic uses (1) Sulfonamides inhibit both gram-negative and gram-positive organisms. The combination is used in the treatment of malaria caused by chloroquine-resistant Plasmodium falciparum. Adverse effects (1) Sulfonamides produce hypersensitivity reactions (rashes, fever, eosinophilia) in approx- imately 3% of individuals receiving oral doses. It is used in combination with other drugs for the treatment of most atypical mycobacteria, including M. Adverse effects of rifampin include nausea and vomiting, dermatitis, and red-orange discol- oration of feces, urine, tears, and sweat. Rifampin induces liver microsomal enzymes and enhances the metabolism of other drugs such as anticoagulants, contraceptives, and corticosteroids. Fluoroquinolones (1) These agents, ciprofloxacin (Cipro), norfloxacin (Noroxin), ofloxacin (Floxin), levoflox- acin (Levaquin), moxifloxacin (Avelox), lomefloxacin (Maxaquin), and gemifloxacin (Factive), are fluorinated analogs of nalidixic acid (NegGram), which is now used infrequently. Moxifloxacin and gemifloxacin have even greater activity against gram-positive organisms. These agents are useful against urinary tract infections and against infections caused by Chapter 11 Drugs Used in Treatment of Infectious Diseases 265 N. Cartilage toxic- ity has been reported, and thus these agents should not be used in children and young adults. Polymyxin is a cationic basic polypeptide that acts as a detergent to disrupt the cell membrane functions of gram-negative bacteria (bactericidal). Polymyxin has substantial nephrotoxicity and neurotoxicity and is therefore only for ophthal- mic, otic, or topical use. Polymyxin B often is applied as a topical ointment in mixture with bacitracin or neomycin, or both (Neosporin). Metronidazole, a prodrug, is bactericidal against most anaerobic bacteria, as well as other organisms, including anaerobic protozoal parasites. Daptomycin (Cubicin) is a very powerful cyclic lipopeptide bactericidal agent that has a spec- trum of activity similar to vancomycin. Myelosuppression and pseudomembranous colitis can occur with the use of this agent. The streptogranins bind the 50S ribosomal subunit and are bactericidal for most organisms. Trimethoprim/sulfamethoxazole, ampicillin, or third-generation cephalosporin Erythromycin Legionella spp. Hepa- totoxicity with jaundice is observed in up to 3% of individuals over age 35. High serum concentrations of this agent may result in peripheral neuropathy; slow acetylators are more susceptible. Structure and mechanism of action (1) Rifampin is a semisynthetic derivative of the antibiotic rifamycin. Resistance, a change in affinity of the polymerase, develops rapidly when the drug is used alone. It enters enterohepatic circulation and induces hepatic mi- crosomes to decrease the half-lives of other drugs, such as anticonvulsants. Structure and mechanism of action (1) Ethambutol inhibits arabinosyl transferases involved in cell wall biosynthesis.

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Abscesses involving the appendix generic aurogra 100 mg fast delivery, liver or biliary tract cheap aurogra 100 mg visa, and colon or rectum were also found to be particularly responsive at rates of 95% order aurogra 100mg online, 85%, and 78%, respectively, although pancreatic abscesses and those involving yeast were correlated with poor outcomes by this treatment method (10). Data is far from optimal, as these critically ill patients cannot ethically be randomized to different treatment groups. However, it would appear at this time that these strategies still are associated with a high mortality of around 42% (12,13). A study by Schein found a particularly high mortality of 55% in the specific subgroup of diffuse postoperative peritonitis treated by planned relaparotomy, with or without open management. Furthermore, Schein went on to state that open management was associated with over twice the mortality of closed: 58% versus 24% (14). Although necessary flaws in study design make it difficult to say whether these approaches offer an advantage over the more traditional ones, it is nevertheless clear that they are far from ideal. The hurdles in addressing the challenge of tertiary peritonitis have led to exploration of potential future therapies. Some are in keeping with traditional surgical/mechanical means: Case studies have reported success of laparoscopy, even in the face of diffuse peritonitis and multiple abscesses (15). Other concepts favor a medicine-based approach, rooted in emerging ideas on the disease’s basic pathology. As it is believed that bacteria migrate out of the intestinal tract secondary to mucosal ischemia and permeability, strategies that support the mucosa, such as early postoperative enteral feeding or selective elimination of endogenous pathogenic bacteria, have each been tried with mixed results. Likewise, it has been argued that the progression from secondary to tertiary peritonitis represents a crippling of the body’s immune system; in support of this belief, granulocyte colony–stimulating factor and interferon-c have each produced limited success in small patient groups, and successfully treated individuals all demonstrated some recovery of immune cell functioning. Another postulate is that a relative lack of corticosteroid exists to fulfill the demands of extreme stress, and it has been suggested that supplying some patients with stress doses of hydrocortisone can improve the vascular effects in early sepsis. Modulation of the inflammatory cascade with activated protein C continues to be investigated, including the associated risk of bleeding. Finally, some researchers have examined the possibility that alleviating the hyper-catabolic state of patients with tertiary peritonitis might decrease mortality. Growth hormone and insulin-like growth factor-1 have both been tried with intermittent positive and negative outcomes (9). Although clindamycin, ampicillin, and the third-generation cephalosporins such as ceftazidime, ceftriaxone, and cefotaxime are the most commonly associated antimicrobials, the newer, broader spectrum quinolones, such as gatifloxacin and moxifloxacin, can also increase risk, and in fact any antibiotic, including, surprisingly, metronidazole and vancomycin, may rarely predispose patients to the disease. Sigmoidoscopy, when performed in equivocal cases, will show whitish or yellowish pseudomembranes overlying the mucosa in 41% of cases, and radiologic studies, although nonspecific, will often show signs of inflammation such as cecal dilatation, air–fluid levels, and mucosal thumbprinting. Even though diagnosis is often confirmed using the enzyme-linked immunoassay, it is worth bearing in mind that these tests are only about 85% sensitive. For moderate-to-severe cases, metronidazole, either orally or intravenously, is the first line of therapy. In the 20% to 30% of patients who will relapse, a second course of metronidazole is recommended, followed by vancomycin enema for persistent symptomatic infection. Other treatments, such as intravenous immunoglobulin, cholestyramine that binds the bacterial toxin, and probiotics such as Lactobacillus, the yeast Saccharomyces boulardii, and even donor feces or “stool transplantations” to seed the regrowth of normal gut flora, have all been tried with success but as yet are not commonly done. Acalculous Cholecystitis Acalculous cholecystitis, with its difficulty in diagnosis and attendant high mortality, should be a consideration in jaundiced postoperative patients. With this in mind, physicians caring for high-risk populations should carefully evaluate the signs and symptoms of this disease, and even a low level of clinical suspicion should prompt more thorough investigation. Risk Factors and Pathophysiology Although the pathogenesis of acalculous cholecystitis has not been entirely elucidated, it is apparent that the critically ill patient is particularly prone. One patient has been reported in the literature with acalculous cholecystitis secondary to a diaphragmatic hernia mechanically obstructing the cystic duct (19). Given these associations, it is likely that there are multiple triggering factors contributing to a common disease state. An experimental form of the disease is produced by a combination of decreased blood flow to the gallbladder, cystic duct obstruction, and bile concentration (21). It can be conjectured that a partially ischemic state, together with the effects of stasis, creates a favorable environment for the growth of enteric bacteria, ultimately leading to inflammation, often with accompanying gangrene, empyema, perforation, and abscess at rates much higher than those seen with calculous cholecystitis (18,20,21). Presentation and Diagnosis In addition to having one or more of the above risk factors, acalculous cholecystitis patients frequently present with the classical signs and symptoms of the calculous form, such as right 264 Wilson upper quadrant pain, Murphy’s sign, nausea and vomiting, abdominal distention, decreased bowel sounds, fever, jaundice, and abdominal mass (19,21); although patients with mental status changes often lack pain and other symptoms, absence of any one clue should not exclude such a serious possibility (18,22). Laboratory values suggesting the diagnosis include leukocytosis, hyperamylasemia, and elevated aminotransferases (22). Ultrasound, by contrast, when searching for the typical signs of thickened gallbladder wall, sludge, pericholecystic fluid, emphysematous change, and hydrops has recently been shown just 30% sensitive in critically ill trauma patients (23). Finally, diagnostic laparoscopy, although invasive, is nevertheless acceptably safe and allows direct visualization of the organ. In many cases, a combination of studies will be necessary to secure a diagnosis (24). Treatment Cholecystectomy, together with antibiotics, is the definitive treatment for acalculous cholecystitis. Laparoscopic surgery may be possible, and this being minimally invasive, might be considered an attractive option in the critically ill patient. Surgeons, however, must be prepared to encounter many possible complications, including the increased likelihood of gangrene and empyema, both of which are difficult to manage laparoscopically, as well as the tendency to encounter adhesions in any postoperative patient. For poor surgical candidates, another treatment option is percutaneous or laparoscopic cholecystotomy. This procedure is safe and effective in relieving sepsis, but is contraindicated in the cases of gangrene and perforation, and of course, subject to all the limitations of laparoscopy (25). Appropriate antibiotic treatment would center on coverage of gut flora, such as b-lactamase inhibitor penicillin along with an anti-anaerobic agent. Colorectal Anastomotic Leakage Risk Factors, Prevalence, and Long-Term Sequelae Approximately 3% to 6% of large-bowel surgical anastomoses constructed by experienced surgeons may leak. Anastomotic breakdown is the most common cause of stricture formation and also predisposes to increased local recurrence of cancer, a lower cancer-specific survival, and poor colorectal function. Risk factors for anastomotic leakage include male gender, obesity, malnutrition, cardiovascular disease and other underlying chronic disease states, steroid use, alcohol abuse, smoking, inflammatory bowel disease, and preoperative pelvic irradiation. Specific operations that predispose to the development of a leak include emergency indications for surgery, low anterior resection, colorectal anastomoses, particularly difficult or long surgeries lasting over two hours, intraoperative septic conditions, and perioperative blood transfusions (26). Diagnosis The diagnosis of an anastomotic leak in the postoperative patient is relatively straightforward. A typical triad indicative of infection includes fever, leukocytosis, and pelvic pain. Given these signs and symptoms, together with the appropriate surgical history, anastomotic leakage should be high on the differential diagnosis. Other clues that might prompt clinical suspicion include absence of bowel sounds on postoperative day 4 or diarrhea before day 7, greater than 400 mL of fluid from an abdominal drain by day 3, and renal failure by day 3. Intra-abdominal Surgical Infections and Their Mimics in Critical Care 265 Treatment Following intravenous fluid resuscitation and antibiotic therapy to cover gut flora, laparotomy to lavage the abdominal cavity and either place a protecting stoma or an end colostomy is generally indicated for the more severe anastomotic leak. Risk Factors Perforated ulcer represents yet another potential source of abdominal infection in the postop- erative patient. Curling’s ulcers, or stress ulcers, affect in particular burn patients with septic complications; Cushing’s ulcers develop in patients with central nervous system pathology involving midbrain damage, such as occurs after head trauma. Risk factors predicting ulcer perforation include smoking, exposure to nonsteroidal anti-inflammatory drugs, cocaine abuse, and Helicobacter pylori infection (27,28). Presentation and Diagnosis Perforation most typically presents as an acute abdomen with sudden onset of pain, occasionally accompanied by nausea and vomiting, diffuse abdominal tenderness, rigidity of the abdominal wall, and ileus. Plain abdominal and upright chest films exhibiting signs of free air may detect 85% of free perforations (30) and is often the radiologic modality of first choice. Treatment Although there has been debate in recent years with regard to a 12-hour period of observation and supportive treatment before proceeding to surgical intervention for perforation, the poor prognosis associated with delay in definitive treatment and the relatively straightforward surgical procedure has persuaded many surgeons against this approach (28). Currently, direct suture repair, often with omental patch reinforcement, is the usual treatment of choice. From there, 266 Wilson impaired opsonization and phagocytosis in these patients allows bacteria to colonize the ascitic fluid and generate an inflammatory reaction. Complications develop secondary to this inflammation, as intravascular blood volume drops and hepatorenal failure predictably ensues. Renal failure is, in fact, the most sensitive predictor of in-hospital mortality (33). Atypical presentations may consist of acute prerenal renal failure or sudden-onset new hepatic encephalopathy with rapidly declining hepatic function. Secondary peritonitis is bacterial peritonitis secondary to a viscus perforation, surgery, abdominal wall infection, or any other acute inflammation of intra-abdominal organs. These indicators are all very sensitive but nonspecific for a diagnosis of secondary peritonitis, and their presence must be weighed against the remaining clinical picture before any firm diagnoses are reached (32). Low dose, short course cefotaxime—2 g twice a day for five days—is generally considered the first-line therapy, but other cephalosporins such as cefonicid, ceftriaxone, ceftizoxime, and ceftazidime are equally effective, and even oral, lower cost antibiotics such as amoxicillin with clavulanic acid will achieve similar results.

S. Ashton. Baylor College of Medicine.

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