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Over 1 year all injuries were documented monthly build evidence for rehabilitation programs order suhagra 100mg visa, cost-effectiveness and by physiotherapist buy suhagra 100 mg free shipping. Marsh1 1Sunway University buy suhagra 100mg, Psychology cheap 100 mg suhagra with mastercard, Bandar Sunway, Malaysia Introduction/Background: A patient’s lack of insight into their defcits following traumatic brain injury can negatively impact on their long-term adaptation and limit their successful reintegration into the community. Material and Methods: The neuropsychologi- cal functioning of a group of 71 adults was assessed at approxi- mately fve years (mean =65 months) following signifcant (i. Neuropsychological assessment included the cognitive domains of attention, verbal memory, and executive functions. In addition to the psychometric measures the patients completed a comprehensive self-report measure which included items on the perceived presence and severity of cognitive and emotional diff- culties. Results: Overall outcome as rated on the Glasgow Outcome Scale was 13 (18%) with severe disability, 22 (31%) with moder- ate disability; and 36 (51%) had made a good recovery. The cor- respondence between the objective and self-report assessment of cognitive functioning was high for prevalence of problems but the patients underestimated the severity of their defcits. For emotional problems patients self-reported a higher prevalence than that found on the psychometric measures of depression and anxiety. Conclu- sion: In general patients are aware of continuing problems with both their cognitive and emotional functioning. However there is a tendency for them to underestimate the severity of their cognitive defcits. The difference between results on the psychometric meas- ures and self-reports for anxiety and depression may illustrate a possible difference between the presence of a clinical disorder and the subjective daily experience of the patients. The type of injuries sus- tained included: subarachnoid haemorrhage, cerebral contusions, skull fractures, intracranial haemorrhage, extradural haematoma J Rehabil Med Suppl 55 Oral Abstracts 13 and diffuse axonal injuries. If not, can we improve it by using simple and inexpensive clinical interventions namely light, melatonin and caffeine? Intervention was consist of melatonin treatment at night and blue light therapy and caffeine treatment in the morning for fve weeks. Detailed visual inspection and micro-structure assessment of sleep recording were performed in order to score sleep stages. With intervention, improvement of sleep stages and/or sleep-wake patterns were detected in 8/10 patients. Cosinor analysis of saliva melatonin results revealed that averaged base- line % rhythmicity was low. Increase in %Melatonin Rhythm following intervention was statistically signifcant (p=0. One of the main limitations to caudal epidural injec- tions is the fairly high failure rate when no imaging guidance is used. Fluoroscopy and ultrasound may help identifying the sacral hiatus and may allow caudal epidural injections to be performed more accurately and safely. Material and Methods: Our purpose was to determine if there are any differences in effcacy and safety of caudal epidural corticoanesthetic injections guided by ultrasound or fuoroscopy in outpatient with subacute or chronic low back pain, refractory to conservative treatment. We conducted a retro- spective study where we evaluated 16 patients in our outpatient clinic, with low back pain related to disk herniation or associated with lumbar spine stenosis, refractory to conservative treatment. A caudal epidural injection (Lidocaine + Depo-medrol) guided by ultrasound or fuoroscopy was performed. We considered injection as successful when: with ultrasound guidance fuid was observed in the sacral canal; with fuoroscopic guidance radio-opaque contrast was observed in the sacral canal. Conclusion: The results showed similar improve- ments in short-term pain relief, function, patient satisfaction and safety with both, ultrasound and fuoroscopic guidance. Con- J Rehabil Med Suppl 55 Oral Abstracts 15 clusion: In Japan, which has a high population aging rate, vertebral low back pain. As part of addressing these matters, the research- body fractures rank high as a cause of interference with a healthy ers came up with the cost-effective lumbar brace and utilizing this life expectancy. The study used the independent 1 t-test to determine the signifcant difference on the functional dis- Marmara University Medical School, Department of Physical ability scores of patients before and after using the cost-effective Medicine and Rehabilitation- Pain Management, Istanbul, Turkey, lumbar brace. The computed t value Introduction/Background: Even though non-surgical treatments of 7. Patients who chose to have surgery and those who chose to have nonsurgical treatments were similar in age, Introduction/Background: A harmonious sagittal spinopelvic align- comorbidity scores and follow-up duration (69. Spinopelvic alignment needs to be included in surgi- culoskeletal symptom that may be either acute or chronic. Breathing exercises, nutrition 1 and psychological interventions do not have consistent evidence P. Centres should Italy consider the addition of other interventions such as inspiratory Introduction/Background: Given the fgures of obesity worldwide, muscle training, self management and integrated disease manage- its impact on disability and on the National Health Systems, it ap- ment which have good evidence. The particular charac- for some interventions such as breathing exercises and psychology. In 2011, the Italian Ministry of Health has acknowledged the need for a multidisciplinar and integrated rehabilitation path- S. Tambunan3 way for severely obese patients with comorbidities including mul- 1Faculty of Medicine, Physical Medicine and Rehabilitation De- tiple rehabilitative settings according to the severity of disability partment of Dr. Cipto Mangunkusumo National General Hospital, and to the phases of instability of the condition. It is important to Jakarta, Indonesia, 2Persahabatan Hospital, Physical Medicine devise pathways of care based on a multidisciplinary approach that and Rehabilitation, Jakarta, Indonesia, 3Dr. Ciptomangunkusumo not only deal with the weight issue in the long term, but, above all, General Hospital, Physical Medicine and Rehabilitation, Jakarta, prevent and treat its complications, improve function and quality Indonesia of life and enhance participation. Treadmill and stationary bicycle training ment on the organizational requisites of rehabilitation units devoted are types of training that involves large muscle groups in the lower to patients affected by severe obesity with comorbidities. In addition, treadmill exercise also involves trunk mus- 2013, the International Society of Physical and Rehabilitation Med- cle. Khan ,1 2 sisted of 10 minutes increase gradually to 30 minutes, 3 sessions 1Royal Melbourne Hospital, Rehabilitation, Melbourne, Australia, per week for 10 sessions. Both groups also received pulmonary 2University of Melbourne, Medicine, Parkville, Australia, 3Royal rehabilitation program. Results: There were 180 low risk cardiac Material and Methods: We have used continuous overnight pulse patients, male (n=137, mean age 56. Our study shows posi- was forwarded to the patient’s community physician for follow-up. Kohzuki Introduction/Background: The health care decision-making system 1Tsukuba University of Technology, Department of Health, Tsuku- requires evidence of the cost-effectiveness of medical therapies. The incremental cost-effectiveness ratio was calculated physical function and greater risk of arteriosclerosis because of based on intervention and health care costs, and the differential in- hypertension, metabolic disturbances, and vascular calcifcation. The Borg scale was used to con- ers charged to decide how limited health care resources should be trol the intensity of training. Therefore, attention and cognition, is a leading complication with detrimental training during hemodialysis session for 12 weeks might improve outcomes during hospitalization among older adults. Cancer rehabilita- Documentation of delirium status at admission improved from 11% tion inpatients have a number of risk factors that could make them to 98%. Material and Methods: Patients presenting requires well-orchestrated effort of multiple disciplines, including to rehabilitation during Apr 2015 and Oct 2015 were identifed referring hospitals beyond the rehabilitation facility. Future studies and as part of their initial physical assessment, calf measurements are needed to tailor the interventions utilizing specifc resources of were taken on both lower extremities. Only 1 patient had a difference in his/her calf measurement to war- Sherrington , S. This presentation re- views the approaches to “treatment” of frailty used in two rand- omized trials to ascertain whether a common approach can be ap- plied both in frailty and pre-frailty. Both applied interdiscipli- nary multifactorial interventions based on phenotypic characteris- 50 tics using Cardiovascular Health Study criteria and comprehensive geriatric assessment. Barrett6 be delivered with coordination from a key staff member (physi- 1Kessler Institute for Rehabilitation, Physical Medicine and Re- cal therapists). Adher- Kessler Institute for Rehabilitation, Occupational Therapy Ser- 4 ence to the interventions was limited in both groups. However, the percentage of obese patients with sarco- ment” programs are feasible and will be associated with beneft if penia has increased. This study aimed to investigate the effect of adequate levels of adherence are achieved. Mate- rial and Methods: A total of 62 patients were randomly assigned 52 to either an experimental group (n=32) or control group (n=30). Results: A statistically signifcant improvement of Specialties and Dentistry, Napoli, Italy, 2Second University of Na- all measures was observed in both the experimental and control ples, Physical and Mental Health and Preventive Medicine, Napoli, groups after intervention (all p<0.

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Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome—a comparative observational study order suhagra on line amex. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized cheap 100 mg suhagra with mastercard, double blind purchase suhagra now, placebo controlled trial purchase suhagra 100mg without a prescription. Characterization of a strain of community-associated methicillin-resistant Staphylococcus aureus widely disseminated in the United States. Skin and soft-tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus. Necrotizing fasciitis caused by community associated methicillin resistant Staphylococcus aureus in Los Angeles. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. Comparative activity of telavancin against isolates of community-associated methicillin-resistant Staphylococcus aureus. Telavancin versus vancomycin for the treatment of complicated skin and skin-structure infections caused by gram-positive organisms. Results of a double-blind, randomized trial of ceftobiprole treatment of complicated skin and skin structure infections caused by gram positive bacteria. Tribble Enteric Diseases Department, Infectious Diseases Directorate, Naval Medical Research Institute, Silver Spring, Maryland, U. Sometimes symptoms begin as early as on the plane ride home, sometimes not until weeks later. In either case, the patient becomes progressively ill, critically so, all the while unknowingly infecting others. The disease spreads, chaos is loosed, and only the timely insight of an awkwardly introverted yet surprisingly attractive physician stands between armageddon and the return of normalcy. Nonetheless, the likelihood of today’s critical care physician having to manage patients with a tropical infection is increasing, as international travel has increased from an estimated 25 million border crossings in 1950 to over 806 million crossings in 2005 (1). To better prepare travelers prior to their trips abroad, the discipline of travel medicine has been refined over the past 25 years, with an increasing reliance upon evidence-based data and the recent publication of practice guidelines (2). This information assists the physician in determining not only what vaccines or prophylactic regimens may help prevent infection in the traveler, but also stresses the importance of safety awareness and environmental risk avoidance. It is no surprise, then, that each year four million travelers returning from developing countries become ill enough that medical intervention is required either en route or upon return home (4). That is not to say there are four million cases of Ebola or African trypanosomiasis every year, but how can the clinician know what illnesses are being seen, and more importantly, which to consider more likely in their patients? Established in 1995, it now comprises 41 travel or tropical medicine clinics (16 in the United States, 25 in other countries representing all continents) that not only report what diagnoses are seen in their facilities, but additional invaluable data such as time to presentation of illness, geographic exposures, adherence to prophylactic measures, etc. With now more than a decade of surveillance information available, it has been shown that febrile illness, dermatologic disorders (especially insect bites), and acute/chronic diarrheal illnesses comprise almost 70% of all travel-related illness (4). An analysis of 6957 travelers with fever revealed that malaria (21%), acute diarrheal disease (15%), respiratory illness (14%), and dengue (6%) were the most commonly identified etiologies (6). Time to presentation can be helpful to the clinician when generating a differential diagnosis (see Table 1). It is helpful to realize that the familiar adage “common things are common” applies also to travel medicine. In a review of 25,023 patients within the GeoSentris database, there were no reported cases of travel-related anthrax, yellow fever, primary amebic meningoencephalitis, poliomyelitis, Rift Valley fever, tularemia, murine typhus, tetanus, diphtheria, rabies, Japanese encephalitis, or Ebola (4). In the same report, of 17,353 patients, only one case each of the following infections was identified: Angiostrongylus cantonensis, hantavirus, cholera, melioi- dosis, Ross River virus, legionellosis, meningococcal meningitis, and African trypanosomiasis. If any of these diagnoses is suspected, an infectious diseases consultation is recommended. As malaria is the single most common life-threatening infection in returning travelers (Table 2), it will be emphasized in this chapter. Other critical care infectious disease syndromes to be Table 2 General Considerations in Potentially Infected Critically Ill Returning Travelers Diagnostic consideration Comments Make accurate traveler- and itinerary-specific Obtain detailed history of sites visited, activities, and potential risk assessment. Incubation periods: short (<10 days); intermediate (10–14 days); prolonged (>21 days) A minimum period of 5–7 days before considering malaria. Narrow the differential diagnosis using clinical progression and specific findings (i. Always consider and perform diagnostic testing to evaluate for malaria if a traveler has been in a malarious region with an appropriate incubation period. Data from 1997–2002 collected through the GeoSentinel global sentinel surveillance identified malaria in 3. Patients with falciparum malaria were more likely to have traveled to sub-Saharan Africa (89%), with the majority (80%) presenting within four weeks of their return. Several important features are noted among those patients who died from their infection. These include: insufficient or inappropriate malaria chemoprophylaxis (90%) and delay in diagnosis and/or effective therapy (40%). Deaths were considered preventable in 85% of cases and were commonly attributed to patient-related decisions/actions and/or contributing medical errors (11). The current recommendations for malaria prophylaxis take into consideration regional antimalarial drug resistance (13). And so, as a result of our population’s increasing travel to malaria-endemic areas as well as oftentimes inadequate adherence to prescribed chemoprophylaxis, it is increasingly likely that today’s critical care physician will encounter patients with malaria. Unfortunately, there are no historical or physical findings pathognomonic for malaria. Therefore, malaria cannot be ruled out by history or physical examination alone (11,19,20). Falciparum malaria often presents without the classic features of cyclical fever, chills, and diaphoresis (21). When the diagnosis of malaria is suspected, examination of Giemsa or Wright-stained peripheral blood thick and thin smears should be performed. Thick smears are more sensitive (larger volume of blood), but are also more difficult to interpret. Thin smears aid in species identification, and higher percentage parasitemias may be evident even to the novice. Venous blood or blood from a peripheral stick is applied to the test card, and within 15 minutes a negative or positive result is apparent. However, serial thick and thin smears are still recommended (although a negative rapid assay, even if falsely negative, likely excludes significant parasitemia). A positive assay should also be followed by examination of the Tropical Infections in Critical Care 325 peripheral smear for confirmation and in order to determine both the species (possibly more than one) and the level of parasitemia. Nonmicroscopic immunochromatographic tests such as 1 the Binax Now Malaria Test assay are rapid and simple to perform. However, they may not detect low parasitemias (<100 parasites/ml), and require microscopic confirmation (24). Parasite density is clinically significant, as a quantitative relationship exists between the level of falciparum parasitemia and mortality (<25,000 parasites/ml ¼ 0. The successful outcome of the patient with malaria relies upon prompt recognition and initiation of effective therapy with a blood schizonticide to rapidly reduce parasitemia (26). However, monotherapy should only be used in areas where treatment efficacy has been recently demonstrated and not for severe malaria (15,27). Unless the patient has received more than 40 mg/kg of quinine in the preceding 48 hours or has received mefloquine within the preceding 12 hours, a loading dose of quinidine is used to rapidly attain effective drug levels (31). A transition to oral therapy can be considered once the parasite density is <1% and the patient can tolerate oral medications (quinidine course ¼ seven days if infection was acquired in southeast Asia, three days if infection was acquired in Africa or South America). The second drug (doxycycline/tetracycline/clindamycin) should continue for a total of seven days. In the management of severe malaria, artesunate is easier and safer to use than quinine (33). A Cochrane review of the literature comparing artesunate with quinine for the treatment of severe malaria concluded that in adults, treatment with artesunate was associated with reduced parasite clearance time and significantly reduced risk of death (relative risk, 0. At other times, clinicians should telephone 770-488-7100 and ask to speak with a 326 Wood-Morris et al.

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For example buy suhagra 100mg with mastercard, the fundus of the eye is the bone discount suhagra, that one gets when the elbow is bumped and retina buy suhagra 100mg on line. However buy suhagra with american express, the fundus of the stomach is inex- the ulnar nerve that runs past the elbow is stimulated plicably the upper portion. Furosemide may be recom- fungiform papillae Broad, flat structures that mended to treat fluid accumulation as a result of house taste buds in the central portion of the dor- kidney disease, fluid in the lungs, congestive heart sum (back) of the tongue. An exam- ple of a common fungus is the yeast organism that fusiform Formed like a spindle: wider in the causes thrush and diaper rash (diaper dermatitis). For example, a fusiform aneurysm is a vascular outpouching that fungus, foot See athlete’s foot. Usually an unim- fusiform aneurysm An outpouching or widening portant isolated finding first evident at birth, funnel of an artery or a vein that is shaped like a spindle. There are several isotopic forms of gallium that dif- fer from it in atomic weight. The citrate form of gallium-68 is used as a radiotracer to locate sites of inflammation and tumor tissue within the body. Gg gallium scan A test to detect sites in the body where cells are multiplying rapidly, such as tumors or areas of inflammation. A small amount of radioactive gallium is injected into a vein, and the element is taken up by cells that are rapidly divid- G In genetics, guanine, one member of the G-C ing. There can be just one enzyme that red blood cells rely heavily on because large stone, hundreds of tiny stones, or any combi- it protects the cells against oxidative stresses. If a gallstone provide early diagnostic clues for a number of dis- blocks the opening to the pancreatic duct, which orders, including cerebral palsy, Parkinson’s dis- opens into the common bile duct, digestive enzymes ease, and Rett syndrome. Gallstones may not cause symptoms or may disaccharide that is made up of two sugars, galac- lead to pain for up to several hours in the upper tose and glucose, that are bound together. Gallstones are most common in damage to the liver, brain, kidneys, and other among women, Native Americans, Mexican organs in infants due to the accumulation of galac- Americans, and people who are overweight. Individuals with galac- Laparoscopic surgery to remove the gallbladder is tosemia cannot tolerate any amount of human or the most common treatment. Dry gangrene is the death of tissue due to vascular insufficiency without bacte- gastric cancer See cancer, gastric. For a gastric emptying study, a patient eats a meal in grene occurs when body tissue is invaded by bacte- which the food or beverage is mixed with a small ria that thrive in areas of low oxygen content. A scanner that acts bacteria are called anaerobic bacteria and include like a Geiger counter is placed over the stomach to the Clostridium family of bacteria. The bacteria gen- monitor the amount of radioactivity in the stomach erate gas and pus; the tissues swells and can for several hours after the test meal. Wet gangrene requires urgent antibiotic treatment and sometimes surgical abnormal emptying of the stomach, the food and radioactive material stay in the stomach longer than drainage. Gastroenteritis has numer- gastrectomy Surgery to remove part or all of the ous causes, including infections (viruses, bacteria, stomach. Gastric atro- phy may result in a lack of digestive juices due to gastroesophageal reflux disease A condition in accompanying shrinkage of the digestive glands. The operation is sometimes called gastric increases the risk of cancer of the esophagus. Treatment may involve the use of antacids or just after birth to a form so mild that it may not be medications to decrease acid production or acceler- diagnosed until old age. Changes in the gene are likely gastroparesis A disease of the muscles of the to be lethal. Gastroparesis may be associated gene, zygotic lethal A gene that is fatal for the with paralysis of the small intestine and colon. The zygote, the cell formed by the union of a sperm and most common underlying cause is diabetes mellitus. The zygote would normally develop into an Gastroparesis is diagnosed via gastric emptying embryo, as instructed by the genetic material within study. A zygotic lethal gene is a mutated version of a normal gene gastroscope A flexible, lighted instrument that is that is essential to the survival of the zygote. Tissue from the stomach can be removed gene deletion The total loss or absence of a through a gastroscope. A gastrostomy may be used for feeding, usually gene duplication An extra copy of a gene. Expressed endoscope is passed through the mouth, throat, and genes include genes that are transcribed into mes- esophagus to the stomach. The genes in a gene due to deficient activity of the enzyme glucocere- family are descended from an ancestral gene. For brosidase, which leads to accumulation of gluco- example, the hemoglobin genes belong to one gene cerebroside in tissues of the body. The five types of family that was created by gene duplication and Gaucher disease encompass a continuum of clinical divergence. They must be near enough to the genital herpes An infection by human herpes target gene to be genetically linked to it and to be virus that is transmitted through intimate contact inherited, usually together with that gene, and with the moist mucous linings of the genitals. When an infected person has a herpes product is a measure of the degree of gene activity. Also known general paresis Progressive dementia and gen- as condyloma acuminatum, condylomata, and vene- eralized paralysis due to chronic inflammation of the real warts. General paresis is a part of late (tertiary) genitalia The male or female reproductive syphilis and is very rare today. The female internal genitalia are the ovaries, Fallopian tubes, uterus, cervix, and vagina. The male internal genitalia are the testes, epididymis, and vas genetic code See code, genetic. Humans and many other higher animals actually have two genetic infantile agranulocytosis See severe genomes—a chromosomal genome and a mito- congenital neutropenia. Several mosomal genome constitutes the genome of the dozen diseases are known to be due to transport human being. The genotype is “giant cell” reflects the fact that microscopic analy- distinct from the expressed features, or phenotype, sis of the tumor reveals large multinucleate cells of the cell, individual, or organism. Treatment is by surgery, usually followed by genu The Latin word for knee, as in genu recur- chemotherapy. The parasite germ cell Either the egg or the sperm cell; a lives in two stages: trophozoites and cysts. Each mature germ cell is haploid, Trophozoites are the active form of the parasite meaning that it has a single set of 23 chromosomes inside the body. The parasites attach to the lining of the small intestine, germ cell tumor A tumor that arises from a germ reproduce, and are swept down the intestine in the cell. Germ cell tumors also may arise in extragonadal sites, reflecting the fact that giardiasis A contagious form of diarrhea caused germ cells travel to diverse areas of the body, such as by the parasite Giardia lamblia. Antiseptic gas; abdominal pain; bloating; nausea; tiredness; mouthwashes may also be recommended. Tests that detect antigens (pro- teins) to Giardia in the feces are especially useful for gland A group of cells that secrete a substance for screening children in day-care settings, and for test- use in the body. The Meibomian glands can become inflamed, a condition termed meibomianitis or mei- gigantism, eunuchoid Extremely tall stature bomitis. Chronic inflammation leads to cysts of the due to the delayed onset of puberty that permits the Meibomian glands, called chalazions. Also known continued growth of the long bones before their as the palpebral gland, tarsal gland, and tarsocon- growing ends (epiphyses) fuse and growth stops. If it occurs afterward, it causes gland, prostate A gland in the male reproduc- disfigurement. Surgery for mass reduction can help tive system that is located just below the bladder. The prostate is composed of glandular tissue and bundles of gigantism, pituitary Extreme growth in height smooth muscle. The prostate gland secretes a milky caused by oversecretion of growth hormone (soma- fluid that is discharged into the urethra at the time totrophin) by the anterior pituitary gland. See tures of pituitary gigantism include thickening of the also prostate enlargement; prostatitis. Pituitary gigantism may be gland, sebaceous One of the skin glands that caused by an adenoma of the pituitary gland, a empty an oily secretion called sebum into the hair benign tumor of the pituitary gland, or other causes.

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Finally discount suhagra 100mg visa, diagnostic laparoscopy purchase suhagra online, although invasive discount suhagra 100 mg otc, is nevertheless acceptably safe and allows direct visualization of the organ discount suhagra 100mg amex. 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. For patients with penicillin allergy, oral fluoroquinolones such as ofloxacin are yet another suitable option, except in those with a history of failed quinolone prophylaxis implying probable resistance. The addition of albumin to an antibiotic regimen has been shown to decrease in-hospital mortality almost two-thirds from 28% to 10%. It is considered especially beneficial for patients with already impaired renal function and a creatinine >91 mmol/L, or advanced liver disease as evidenced by serum bilirubin >68 mmol/L (33). Fluoroquinolones, such as norfloxacin and ciprofloxacin, are the antimicrobials recommended for prophylactic purposes (33). Among this subset, infected pancreatic necrosis is the leading cause of death (39). Presentation and Diagnosis In addition to the typical signs and symptoms of pancreatitis, such as moderate epigastric pain radiating to the back, vomiting, tachycardia, fever, leukocytosis, and elevated amylase and lipase, patients with severe acute pancreatitis present with relatively greater abdominal tenderness, distension, and even symptoms of accompanying multiorgan failure (38). In these patients, the intensivist must maintain a high level of clinical suspicion for necrosis and possibly infection as well. Infection is estimated to develop in 30% to 70% of patients with necrotic pancreatitis (40). However, necrosis both with and without infection often manifest with similar clinical presentations because necrosis alone causes a systemic inflammatory response, and additional diagnostic data is generally needed to differentiate these (41). Enterococcus species are the organisms most frequently isolated, although many different pathogens including Candida spp. Treatment and Prophylaxis The distinction between sterile and infected necrotic pancreatitis is crucial, as the former may be handled medically when necrosis affects less than 30% of the organ, whereas the latter often demands surgical debridement (38). Recently, several studies have explored the potential of laparoscopy for infectious pancreatic necrosis, but this approach is rarely feasible in instances of extensive necrosis, and data is not yet sufficient to compare the safety and efficacy of 268 Wilson laparoscopic surgery versus laparotomy for this indication (43). Percutaneous drainage has a low success rate of just 32% and is generally insufficient management except in the case of a well-defined abscess, or one remote from the pancreas (41). Abdominal compartment syndrome has been noted in severe acute pancreatitis and decompression has been suggested for patients whose transvesical intra-abdominal pressure reaches 10 to 12 mm Hg (43). An appropriate antibiotic regimen for infected pancreatic necrosis is the second arm of a successful treatment plan: given the wide range of possible offending organisms, a Gram stain is recommended to tailor specific initial therapies prior to culture results. For gram-negative organisms, a single-agent carbapenem is effective; for gram-positives b-lactamase–resistant drugs, vancomycin, and even linezolid must considered. When yeast is identified, high-dose fluconazole or caspofungin should be sufficient. In any case, if infection develops despite antibiotic prophylaxis, a different class of drugs must be administered for treatment than was given for prophylaxis (44). Although current literature does not specifically favor any specific antibiotic as prophylaxis, it is nonetheless clear that microbial coverage must be broadly targeted. One- to two-week courses of cefuroxime, imipenem with cilastin, and ofloxacin with metronidazole have each been tried with success (42). An exhaustive list of these is beyond the scope of this chapter; however, the reader should be aware of the general possibilities. Fever, for instance, in the postoperative patient, is not always secondary to infection. Particularly relevant to the postsurgical patient are events such as atelectasis, myocardial infarction, stroke, hematoma formation, and even pulmonary embolism that may occasionally present with a fever component. Other causes that warrant deliberation include drug or transfusion reaction, malignancy, collagen vascular disease, endocrine causes such as hyperthyroidism, and less common etiologies such as disordered heat homeostasis secondary to an ischemic hypothalamic injury or even familial malignant hyperthermia. Furthermore, it is important to interpret radiological findings with an open mind. Again, high on the differential that must be considered is hematoma, and one may explore other diagnoses given the individual patient history. A myocardial infarction involving the inferior wall of the heart and lower lobe pneumonias, for instance, may present with abdominal pain and fever despite extra-abdominal origins. Approximately 40% of all organisms isolated by DeWaele and colleagues at Ghent University hospital were multidrug resistant. For example, a patient’s status post-aneurysm repair has the same likelihood of developing appendicitis as any member of the general population in the same age group. Therefore, the conscientious physician considers all possibilities appropriate for the patient’s complete history—not surgical history only—when constructing a thorough differential. Longitudinal outcomes of intra-abdominal infection complicated by critical illness.

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