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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Postexposure prophylaxis for rabies may be indicated; Evidence Summary consultation with local health officials is recommended to de- Purulent bite wounds and abscess are more likely to be polymi- termine if vaccination should be initiated (strong purchase cheap champix, low) order champix without prescription. Pasteurella species are commonly isolated from both non- verse and nonstandardized approaches to basic wound care and purulent wounds with or without lymphangitis and from ab- a variety of antimicrobial agents buy 0.5/1mg champix mastercard, have failed to definitively de- scesses. Additionally, nonpurulent wound infections may also termine who should receive early, preemptive therapy for bite be polymicrobial [156]. Consequently, the decision to give “prophylactic” an- Based on this bacteriology, amoxicillin-clavulanate is appro- tibiotics should be based on wound severity and host immune priate oral therapy that covers the most likely aerobes and an- competence [147, 148]. A carbapenem, moxi- puncture wounds; those in patients with no history of an immu- floxacin, or doxycycline is also appropriate. Unless no alternative meta-analysis of 8 randomized trials of dog bite wounds agents are available, macrolides should be avoided due to vari- found a cumulative incidence of infection of 16%, with a relative able activity against Pasteurella multocida and fusobacteria. The bacteriologic characteristics of the bite resulted in a lower infection rate [144]. Recommended Therapy for Infections Following Animal or Human Bites Therapy Type Antimicrobial Agent by Type of Bite Oral Intravenous Comments Animal bite Amoxicillin-clavulanate 875/125 mg bid. Should Tetanus Toxoid Be Administered for Animal Bite macrolides, clindamycin, and aminoglycosides (Table 5). Therefore, treatment with amoxicillin-clavulanate, ampicillin- Recommendation sulbactam, or ertapenem is recommended; if there is history 43. Tetanus toxoid should be administered to patients with- of hypersensitivity to β-lactams, a fluoroquinolone, such as cip- out toxoid vaccination within 10 years. Tetanus, diptheria, and rofloxacin or levofloxacin plus metronidazole, or moxifloxacin pertussis (Tdap) is preferred over Tetanus and diptheria (Td) if as a single agent is recommended. Broader empirical coverage the former has not been previously given (strong, low). Additional- ly, a more focused therapy for nonpurulent infected wounds Evidence Summary could allow narrower therapy. Cultures are often not done on Tetanus is a severe and often fatal disease preventable through wounds, and empirical therapy might miss pathogens. Although no recent cases of tetanus from a bite have been reported, dogs and cats are coprophagic and could poten- Evidence Summary tially transmit tetanus. Administering tetanus vaccine/toxoid One of several clinical manifestations of anthrax is a cutaneous after animal bite wounds is predicated upon the Advisory Com- lesion. The benefits of regular tetanus toxoid boosters in adults on top of the papule, and, finally, a painless ulcer with a black who have had a primary series have been questioned although scab. This eschar generally separates and sloughs after 12–14 its use in “dirty wounds” seems sensible [161,162]. Variable amounts of swelling that range from minimal have not completed the vaccine series should do so. Mildto dose of tetanus toxoid vaccine should be administered for dirty moderate fever, headaches, and malaise often accompany the wounds if >5 years has elapsed since the last dose and for clean illness. Tdap is preferred over Td if the former has lesion is absent unless a secondary infection occurs. In Which Patients Is Primary Wound Closure Appropriate for of untreated lesions, depending upon the stage of evolution, are Animal Bite Wounds? Methods of specimen collection for Recommendation culture depend on the type of lesion. Primary wound closure is not recommended for wounds blistershouldbeunroofedand2dryswabssoakedinthe with the exception of those to the face, which should be man- fluid. At a later stage, 2 moist swabs should be rotated in aged with copious irrigation, cautious debridement, and pre- the ulcer base or beneath the eschar’s edge. Other wounds may be previously received antimicrobials or have negative studies, but approximated (weak, low). When obtaining specimens, lesions should not be ment in bite wound management, limited randomized con- squeezed to produce material for culture. Additional diagnostic trolled studies have addressed the issue of wound closure methods may include serological and skin tests. In one study, primary closure of dog No randomized, controlled trials of therapy of cutaneous an- bite lacerations and perforations was associated with an infec- thrax exist. Most published data indicate that penicillin is effec- tion rate of <1% [163], but closing wounds of the hand may tive therapy and will “sterilize” most lesions within a few hours be associated with a higher infection rate than other locations to 3 days but does not accelerate healing. Based on their 10-year experience with 116 patients, primarily in reducing mortality from as high as 20% to zero. Schultz and McMaster recommend that excised wounds, but Based on even less evidence, tetracyclines, chloramphenicol, not puncture wounds, should be closed [164]. The optimal duration of treatment is un- recommendations have major limitations including lack of a certain, but 7–10 days appears adequate in naturally acquired control group and their anecdotal nature, and lack of standard- cases. Sixty days of treatment is recommended when associated ization of the type of wound, its location, severity, or circum- with bioterrorism as concomitant inhalation may have stances surrounding the injury. Until susceptibilities are available, ciprofloxacin is are copiously irrigated and treated with preemptive antimicro- rational empiric therapy for bioterrorism-related cases. Oral penicillin V 500 mg qid for 7–10 days is the recom- Some have suggested systemic corticosteroids for patients mended treatment for naturally acquired cutaneous anthrax who develop malignant edema, especially of the head and (strong, high). What Is the Appropriate Approach for the Evaluation and of initial therapy, while not standardized, should be for 2 weeks Treatment of Bacillary Angiomatosis and Cat Scratch Disease?

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Contraction Transverse Abdominis Muscle oftheexternalabdominalobliqueononesideandthe internal oblique on the opposite side results in rotation the transverse abdominis (Figs generic champix 1mg free shipping. Transverse abdominis muscle and aponeu- rosis Erector Spinae and Transversospinalis Muscles Quadratus Lumborum Transverse Anterior buy 1mg champix with amex, Middle Abdominis and Posterior Muscle Layers of the Thoracolumbar Fascia Fig safe champix 1mg. Cross section of the postero- Vertebral canal Psoa Major lateral abdominal wall showing the muscle external and internal abdominal oblique, transverse abdominis, and Internal Abdominal External Abdominal the thoracolumbar fascia Oblique Muscle Oblique Muscle 16 1 Anatomy of the Abdominal Wall Sternal Angle of Louis theaponeurosisoftheinternalabdominalobliqueand the external oblique to form the anterior layer of the rectus sheath. Inferior to the midpoint, the transverse aponeurosisrunsposteriortotherectusabdominis Xyphoid and anterior to the muscle. The lower fibers of the apo- Process neurosis curve downward and medially and join the aponeurosis of the internal abdominal oblique at the Linea Alba pubic crest to form the conjoint tendon. Rectus Abdominis Muscle Tendinous Umbilicus Intersections Pubic Symphuysis Pubic Tubercle Internal Intercostal Muscle Skin (Cut) Latissimus Dorsi Fig. Rectus abdominis muscle in relation to the transverse abdominis and superficial fascia of the abdomen Iliac Crest Transverse Abdominis Muscle and Aponeurosis zontal course deep to the internal abdominal oblique muscle. It maintains a similar origin to the internal oblique, arising from the thoracolumbar fascia, iliac crest and the lateral third of the inguinal ligament. The transverse abdominis receives additional origin from the inner surface of the lower five or six ribs, partly in- 1. This muscle may be absent or fused with the internal abdominal oblique and may contain openings This muscle is innervated by the ventral rami of the filled with fascia. It becomes aponeurotic as it ap- lowerfiveorsixintercostalnerves,aswellasbythesub- proaches the lateral border of the rectus abdominis, costal, iliohypogastric and ilioinguinal nerves. Superior to the midpoint between the umbilicus and the effect of contraction of the transverse abdominis symphysis pubis (upper two-thirds), the aponeurosis on the vertebral column is not clear, despite its role as a of the transverse abdominis joins the anterior layer of compressive force resisting intra-abdominal pressure. Posterior layer of the rectus sheath, arcuate line of Douglas, internal abdominal oblique, and transverse abdominis It is believed that the actions of the transverse abdomi- the recti muscles are completely separated in the mid- nisarebasicallycommontotheinternalandexternal line above the umbilicus by the linea alba and less so abdominal oblique muscles. Its lateral border forms the semilunar line, a is believed to respond more to increases in chemical or curved groove that extends from the pubic tubercle to volume-related drive than the rectus abdominis and the ninth costal cartilage, which is particularly visible externalabdominaloblique. This muscle is usually inter- roanatomical studies that have demonstrated many rupted by three transversely running tendinous inter- more inputs to, and outputs from, the motor neurons sections that assume a zigzag path and firmly adhere to that innervate the transverse abdominis muscle than the anterior layer of the rectus sheath. A parame- mally, it attaches to the xiphoid process and the costal dian incision that cuts through the anterior layer of the cartilages of the fifth through the seventh ribs. Distally rectus sheath and rectus abdominis carries the advan- it attaches via a medial tendon to the pubic symphysis, tage of protecting the sutured peritoneum when the interlacing with the opposite muscle and via a lateral rectusabdominisslipsbackintoitsproperanatomical tendon to the pubic crest, extending to the pecten pubis position. There- cartilages, and the anterior layer of the sheath at this fore, the rectus abdominis can surgically be transected levelisformedonlybytheexternalobliqueaponeuro- anywhere other than the sites of these fibrous intersect- sis. Immediately below the costal margin, the trans- ions, without possible threat of herniation. Cosmetic verse abdominis muscle extends posterior to the rectus [30] results are greatly enhanced when the approxima- muscle. The rectus sheath contains the pyramidalis tion of the recti muscles is combined with a flap ad- muscle, the superior and inferior epigastric vessels and vancement and rotation of the external abdominal the terminal branches of the lower five or six intercostal oblique muscle. This line corre- should alert the surgeon for this very possibility [31, sponds to the midpoint between the umbilicus and the 32]. Proximaltothearcuatelinetheapo- recti by a stretching or widening of the linea alba, is neuroses of the external abdominal oblique and the an- commonly associated with parturition. The rectus abdominis muscle is segmentally innervat- Distal to the arcuate line, the anterior layer of the rectus ed by the ventral rami of the lower six or seven thoracic sheath is formed by the combined aponeuroses of the spinal nerves. Since the aponeuroses of the internal oblique and With the pelvis fixed, the recti act as flexors of the lum- transverse abdominis only extend to the costal margin, bar vertebral column; with the thorax fixed, they draw the rectus abdominis above this level rests on the costal the pelvis upward. The recti come to action as flexors, Transverse Abdominis Muscle Transversalis Fascia Transversalis Fascia Peritoneum Internal Inferior Epigastric Median Umbilical Medial Umbilical Abdominal Artery and Vein Ligament (Urachus) Ligament Oblique Muscle Pyramidalis Deep Rectus Abdominis Muscle Inguinal External Ring Abdominal Deep Oblique Muscle Inguinal & Aponeurosis Ring Transverse Intercrural Fibers Internal External Spermatic Fascia Spermatic Fascia Superficial Cremasteric Inguinal Muscle and Fascia Femoral Artery Ring and Vein Hernial Sac Fig. Observetheinguinalcanal,inferior epigastricvesselsand the pro- truding hernial sac 1. The study conducted by Teoh [38] con- which is absent in approximately 25% of the popula- firmed the presence of the iliopubic tract as a thicken- tion, originates from the symphysis pubis and pubic ing of the transversalis fascia that runs parallel to the crest and inserts into the linea alba as far as one-third of inguinal ligament and believed to be a significant the distance to the umbilicus. This triangular muscle structure in various approaches to repair of inguinal lies anterior to the lower end of the rectus abdominis hernia. It attaches to the superomedial part of the pubic and becomes smaller and pointed as it ascends towards bone medially, but laterally it joins the iliac fascia with the junction of the linea alba and the arcuate line. It is loose and fatty in the lowest portion, allowing for the expansion of the blad- 1. The potential space represented by this loose pre- Transversalis Fascia peritoneal layer, the space of Bogros, is used for the placement of prostheses in the repair of inguinal her- the transversalis fascia [33, 34] is a segment of the en- nia. This layer is particularly thick and fatty in the pos- doabdominal fascia that forms the lining of the entire terior abdomen as it surrounds the major vessels and abdominal cavity. It contributes to the posterior wall of also the kidney to form the perinephric renal capsule. It lies between the transverse ab- dominis and the extraperitoneal fat and continues infe- riorly with the iliac and pelvic fascia and superiorly 1. Peritoneum Although it is a very thin layer on the inferior surface of the diaphragm, it shows some thickening in the ingui- the peritoneum is part of the coelomic cavity that be- nal region. In the posterior abdominal wall it joins the comes separated from the pleural cavities by the devel- anterior layer of the thoracolumbar fascia. Thefreesurfaceofthisex- versalis fascia attaches to the iliac crest and to the pos- tensive membrane is covered by a layer of mesotheli- terior margin of the inguinal ligament as well as to the um, saturated by a thin film of serous fluid. Its prolongation neum is a serous membrane that resembles, but is around the spermatic cord, known as the internal sper- much more complicated than, the pleura essentially matic fascia, fuses with the parietal layer of the tunica duetothefactthatinthecourseoffetaldevelopment vaginalis. It blends with the iliac fascia as it forms the rotations of the gut allow certain parts of the abdomi- anterior layer of the femoral sheath. Anterior to the femoral vessels, the transversalis fas- However, this process does not occur in the thoracic ciaisaugmentedbythetransversecruralarch,ahori- cavity and the pleura maintains a much simpler ar- zontally disposed layer that descends to attach medially rangement.

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  • Is it always swollen, or does it come and go?
  • Anemia
  • Paranoia and other delusions
  • A scar that is thickened.
  • Abdomen
  • Trichomoniasis
  • Muscle twitches (fasciculations)
  • Damage to nearby organs in the body and nerves in the pelvis

The same data instead showed a better performance in terms of a diagnosis of complicated acute appendicitis in obese patients (when matched with larg- er laparotomies than McBurney incision) and in elderly patients in whom post- operative rehabilitation was more rapid order champix without a prescription. In the latter case the laparoscopic approach was unable to identify the appendix due to a serious intra-abdominal inflammatory condition and to an extensive pattern of pericecal adhesions withh reduced work space buy champix mastercard. Interval appendectomy was planned after a strictly clinical andd instrumental follow-up cheap champix 0.5/1 mg with mastercard, but patients denied consent to the operation due to optimal clinical conditions. Currently, at 13 months from clinical presentation, the patient is totally asymptomatic, and this condition has been confirmed by instrumental examinations. About 3 months later he suffered from abdominal pain and fever and underwent laparo- scopic interval appendectomy with drainage of the residual collection. The last patient of this series underwent drainage after an emergent xipho- pubic laparotomy. There was no evidence of appendicular perforation and the resec- tion margin was intact. A repeat procedure was performedd and about 1000 mL of blood was evacuated from the abdomen due to left epi- gastric vessel lesion. In two patients who had undergone previous laparotomies, the insertion off the optic trocar by open technique at the site of umbilical scar caused a bowel loop lesion due to the massive adherence of the bowel loops with the previous laparotomic scar. Earlier laparotomy (2nd postopera- tive day) with direct suture of the bowel lesion solved the problem with a good patient outcome. One patient with a leakage from the appendicular stump (histologic finding of appendix showed suspected Crohn disease) was successfully treated with medical therapy alone (antibiotic and infusive treatment). Minor complications occurred in 11 patients: three trocar site incisional hernias and eight umbilical trocar site infections (respectively in two and fourr obese patients). This elevated the mean hospital stay (about 7 days), with a negative effect on postoperative outcomes (pain, oral intake, and return to job) and with an increase in parietal complica- tions (scar infection in obese patient). The causes of conversion were anatomical (no recognized appendix, bowel adhesions, extensive acute inflammation due to complicated appendicitis) and in one case an unforeseen perforated sigmoid diverticulum. This technique has several limitations: longer operative times, greaterr engagement of the organization (it requires a skilled surgical team – surgeons, nurses, anesthetist – especially in emergent procedures and at night), higherr costs (due to longer operative times and for the technology of materials need- ed for the operation). They report discordant data, in part due to the poor quality of the methodological and statistic criteria used [9]. In our experience too, at the beginning, the technique was used for the learning curve of the surgeon in laparoscopic surgery training, but now we can say that we use the mini-invasive technique in all cases, even in complicated acute appendicitis, except when laparoscopy is generally contraindicated. With the passing of time, thanks to better work organization (better skill off surgical teams in emergent laparoscopic procedures performed right around the clock,shorter operative times and lower costs of laparoscopic materials) and moreover thanks to of the large number of procedures performed overr 70 A. This is especially true for women in pre- menopausal age, in whom there is solid evidence of the advantages off laparoscopy. Particularr attention should be paid to elderly patients in whom there is a high risk off perforation. Some of the advantages in young patients can also be found in the elderly with acute appendicitis, although reaching a correct diagnosis is crucial given the high risk of complicated forms. The advantages of laparoscopic surgery in obese patients have been amply described. These include better exploration of the abdominal cavity and less parietal injury than in larger laparotomies. The advantages of the laparoscop- ic technique are particularly notable in obese patients: less postoperative pain, less parietal septic complications, less incidence of incisional hernias, less adhesive syndrome [11]. These advantages seem more evident in obese patients particularly when the appendicitis is complicated, given the lowerr incidence of complications (from 27% to 18%) and lower costs than open sur- gery in obese patients with a diagnosis of perforated appendicitis [18]. These figures are similar to those of Cochrane Database off Systematic Reviews [22]. This large database from a review of 54 controlled randomized trials, with about 5000 patients, shows an intra-abdominal infection rate of 0. These results have been criticized for the quality of the studies and have nott been confirmed by the experiences of other authors. Given their experience, they consider the technique to be safe and useful even in more complex situations, where laparoscopy is unable to offer reduced parietal damage or a complete exploration of the abdominal cavity and exten- sive lavage of the peritoneal recesses [24, 25]. Apart from a retrospective paper thatt suggests extensive lavage as a possible cause of contamination and postopera- tive abscesses, there is an experimental study that relies on at least 6 L of lavage 72 A. Particularly in these circumstances the surgeon’s skill and a well codified technique are fundamental for achieving an optimal result and for reducing the overall complication rate and the overall conversion rate to open surgery. In fact, although it is often a mandatory choice forr patient safety, it is also true that it can have negative consequences on postop- erative outcomes (overall hospital stay, postoperative pain, oral intake and return to work) and on parietal complications (increased risk of infection off the laparotomic scar). More frequent causes of mandatory conversion include anatomic condi- tions, especially in complicated cases, such as reduced abdominal working space, failure to identify the appendix and dense visceral adhesions. The number of laparoscopic procedures performed by a surgeon over the years seems to play a decisive role in the frequency of conversion, as shown by Hellberg et al. This seems to confirm that conversion is strictly related not only to the severity of the clinical and anatomopathologic pattern, but also to experience acquired by the surgeon in laparoscopic surgery. The type off procedure to be performed is a matter of debate: a simple appendectomy (laparoscopic, after immediate conversion or if open appendectomy is manda- tory? In this case, we think that the uninjured resection margins of the speci- men with no perforation signs (benign mucocele) and a gentle manipulation off the appendix enabled mini-invasive treatment to be performed safely enough to avoid the possible iatrogenic spread of the disease to the peritoneum ((pseudomyxoma peritonei) [29, 30]. We obtained complete remission of the clinical condition in three patients and appendectomy was not necessary.


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