Patients with evidence of secondary peritonitis should be referred immediately for surgical evaluation. Prompt surgery is the mainstay of treatment for patients with secondary peritonitis to control the source of contamination and to remove necrotic tissue, blood, or intestinal contents from the peritoneal cavity. Medical management consists of antimicrobial therapy and physiologic support of the patient. The mortality rate of secondary peritonitis approaches 100% if treatment does not include surgical intervention.The choice of antimicrobial agents is generally made empirically, based on the likely pathogens. Although no clinical trials have demonstrated the superiority of one antimicrobial regimen over the other/it is known that both anaerobes and gram-negative aerobes should be covered. Combination antimicrobial therapy has traditionally been used, although single broad-spectrum agents, including beta-lactam/beta-lactamase inhibitor combinations and the carbapenems, are alternatives. Recommendations for empiric therapy depend on the severity of illness and whether the infection was acquired in a community or hospital setting. The duration of antimicrobial therapy after surgery is usually 5 to 7 days, depending on the severity of the infection, clinical response, and normalization of the white blood cell count.The role of enterococci in secondary peritonitis is not clearly defined, as most cases of secondary peritonitis are cured with regimens that do not have activity against enterococcus. However, regimens that include specific enterococcal coverage are recommended if these organisms grow in a pure culture from an intra-abdominal source of infection or from the blood.*93/348/5*
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TREATMENT OF SECONDARY PERITONITIS
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WOMEN AS VICTIMS OF DOMESTIC VIOLENCE
Comments OffWhile young men are more apt to become victims of violent acts perpetrated by strangers, women are much more likely to become victims of violent acts perpetrated by spouses, lovers, ex-spouses, and ex-lovers. In 1999, more than 6 million women were victims of assault. In fact, 6 of every 10 women in the United States will be assaulted at some time in their lives by someone they know. Every year, approximately 12 percent of married women are the victims of physical aggression perpetrated by their husbands, according to a national survey. These acts of aggression are committed in anger and often include pushing, slapping, and shoving.Some women experience much more severe acts of aggression. Each year about 4 percent of married women are the victims of violence that takes the form of beating and/or threats of or actual harm caused by use of a knife or a gun. In fact, acts of aggression by a husband or boyfriend are one of the most common causes of death for young women, and roughly 2,200 women in the United States are killed each year by their partners or ex-partners. Over a recent 10-year period, according to the National Crime Survey, on average, more than 2 million assaults on women occurred each year. More than two thirds of these assaults were committed by someone the woman knew.The following U.S. statistics indicate the seriousness of this long-hidden problem:- The most vulnerable female victims are African American and Hispanic, live in large cities, are young and unmarried, and are far from their families.- Every 15 seconds, someone batters a woman.- Only 1 in every 250 such assaults is reported to the police.- More than a third of women victims of domestic violence are severely abused on a regular basis.- About five women are killed every day in domestic violence incidents.- Three of every four women murdered are killed by their husbands.- Domestic violence is the single greatest cause of injury to women, surpassing rape, mugging, and auto accidents combined.- About 25 to 45 percent of all women who are battered sustain such attacks during pregnancy.- One quarter of suicide attempts by women occur as a result of domestic violence.How many times have you heard of a woman who is repeatedly beaten by her partner or spouse and asked, “Why doesn’t she just leave him?” There are many reasons why some women find it difficult, if not impossible, to break their ties with their abusers. Many women, particularly those with small children, often are financially dependent on their partners. Others fear retaliation against themselves or their children. Some women hope that the situation will change with time (it rarely does), and others stay because their cultural or religious beliefs forbid divorce. Finally, some women still love the abusive partner and are concerned about what will happen to him if they leave.Psychologist Lenore Walker developed a theory known as the “cycle of violence” to explain how women can get caught in a downward spiral without knowing what is happening to them. The cycle has three phases:1. Tension building. In this phase, minor battering occurs, and the woman may become more nurturant, more pleasing, and more intent on anticipating the spouse’s needs in order to forestall another violent scene. She assumes guilt for doing something to provoke him and tries hard to avoid doing it again.- Acute battering. At this stage, pleasing her man doesn’t help and she can no longer control or predict the abuse. Usually, the spouse is trying to “teach her a lesson,” and when he feels he has inflicted enough pain, he’ll stop. When the acute attack is over, he may respond with shock and denial about his own behavior. Both batterer and victim may soft-pedal the seriousness of the attacks.- Remorse/reconciliation. During this “honeymoon” period, the batterer may be kind, loving, and apologetic, swearing he will never act violently toward the woman again. He may “behave” for several weeks or months, and the woman may come to question whether she overrated the seriousness of past abuse.- Then the kind of tension that precipitated abusive incidents in the past resurfaces, the man loses control again and he once more beats the woman.Unless some form of intervention breaks this downward cycle of abuse, contrition, further abuse, denial, and contrition, it will repeat itself again and again – perhaps ending only in the woman’s, or rarely, the man’s death.It is very hard for most women who get caught in this cycle of violence (which may include forced sexual relations and psychological and economic abuse as well as beatings) to summon up the courage and resolution to extricate themselves. Most need effective outside intervention.*2/277/5*
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WHO GETS OCD: MARTIN LUTHER AND IGNATIUS OF LOYOLA
Comments OffLastly, we may consider two great historical figures who, even though they were bitter enemies, had much in common. Both marked turning points in 1521: Luther was condemned by the Catholic Church as a heretic; and Ignatius of Loyola experienced religious conversion. Both men started great movements: Luther, the Reformation; and Ignatius, the Jesuits. Both men, too, suffered obsessions.Martin Luther underwent severe mental turmoil with obsessions and depression. In Young Man Luther, the psychiatrist Erik Erikson notes that during his first years in the monastery, Luther’s mental state was so disrupted that “it seems entirely probable that young Luther’s life at times approached what today we might call a borderline psychotic state.” Ignatius endured similar, if not quite so severe, afflictions. W. W. Meisner, M.D., writes in his biography Ignatius of Loyola that Ignatius’s early life was “filled with inner torment” due to “intense, destructive obsessions.”Luther and Ignatius both endured tormenting obsessional doubts and, to a lesser degree, other types of obsessions as well. Religious doubts, a form of scruples, were indeed a common problem in past centuries; they qualify as obsessions when they are persistent, tormenting, and recognized as inappropriate. Luther writes in his Commentary on Galatians:
When I was a monk I thought that I was utterly cast away. If at any time I felt fleshly lust, wrath, hatred, or envy against any brother, I assayed many ways to quiet my conscience, but it would not be; for the lust did always return, so that I could not rest, but was continually vexed with these thoughts: This or that sin thou hast committed: thou art infected with envy, with impatiency, and such other sins.
Because of these excruciating scruples, Luther could not feel certain that he had confessed all his sins. He would confess for hours and hours, splitting his transgressions smaller and smaller. He would go back to childhood and endlessly enumerate possibly sinful acts. After finishing he would ask for special appointments to correct previous statements. His preceptors, confused by his possessiveness, threatened to punish him for obstruction of confession. As quoted in The Way of Interior Peace, one of them told Luther: “You have no real sins with which to reproach yourself. . . give up your nonsensical and ludicrous notions.”Ignatius suffered similar battles with confessional scruples. He writes in his autobiography St. Ignatius’ Own Story:
Even though I had confessed . . . my scruples returned, each time becoming mote minute, so that I became quite upset, and although I knew that these scruples were doing me much harm, and that it would be good to be rid of them, I could not shake them off. … I continued with my seven hours of prayer on my knees, rising faithfully every midnight, and performing all the other exercises. But nothing provided me with a cute for my scruples.
Luther and Ignatius also suffered violent and blasphemous obsessions. Luther once declared at the dinner table that the sight of a knife conjured up “painful pictures” before him. He writes: “For more than a week I have been thrown back and forth in death andHell; my whole body feels beaten, my limbs are still trembling. I almost lost Christ completely, driven about on the waves and storms of despair and blasphemy against God.” Ignatius notes: “While these thoughts were tormenting me, I was frequently seized with the temptation to throw myself into an excavation close to my room. But, knowing that it was a sin, I cried again: ‘Lord, I will do nothing to offend you,’ and I frequently repeated these words.”Who knows how many other great historical figures suffered obsessions? Charles Darwin, arguably the single most influential scientist who ever lived, suffered frequent attacks of heart palpitations, shortness of breath, fainting, a buzzing noise in his head, stomach pains, and eczema. Most of his recent biographers agree that he had panic disorder. Darwin’s letters and diaries suggest he may have also been plagued by obsessions. Darwin mentions having “much involuntary fear” and sudden “insane feelings of anger.” He reports: “I awake in the night and feel so much afraid, though my reason laughs and tells me there is nothing to fear. … By habit the mind fixes on the same object.” In the 1977 medical biography of Darwin, To Be an Invalid, Ralph Cope, Jr., M.D., concludes that Darwin was “tortured by obsessional thoughts.”*19/338/2*