Treatment of intra-abdominal infections is without doubt one of the most common and important challenges for surgeons generally and for those who work in low-income countries, in particular. Despite the development of much ancillary diagnostic technology, the diagnosis of peritonitis is still dependent on clinical criteria. Operative management, which may require repeated laparotomies, may tax the skills of the most experienced surgeon.
A multi-disciplinary approach to intensive care support of the critically ill patient may be as important to survival as surgery. Controlling the source of infection, removing contamination by peritoneal lavage, antibiotics and physiologic support remain the chief modalities of treatment. (2) Intra-abdominal infections comprise a) infections of specific organ systems, eg. appendicitis, and cholecystitis; b) peritonitis resulting from extension of infection into the general peritoneal cavity and c) intra-abdominal abscesses which result from the extension of inflammation beyond the viscus and from incompletely resolved peritonitis. (3) The latter two entities comprise the subject of this Review.
In the US and Canada, optometrists are considered Doctors of Optometry. They are required to complete medical training as well as the specialized training needed to diagnose illnesses of the eye. Doctors of optometry are able to perform medical procedures including laser treatments. Their medical training also allows them to treat diseases through ingested medications and topical solutions. As a result of their medical training, optometrists who are certified doctors are subject the same laws as other medical doctors when it comes to their practice and their patients.
In other parts of the world, including the United Kingdom, those seeking to pursue optometry are not required to undertake medical training. The care they are able to provide their patients is limited to monitoring the health of the eye and providing prescriptions for corrective eyeglasses or bi-weekly contact lenses for comfortable vision. Because they lack medical training they are unable to issue prescriptions for medication in the form of drugs or topical solutions. Furthermore, they do not have the power or training to perform invasive procedures including surgery and laser treatments. If a patient requires such treatment, he or she is referred to an ophthalmologist, a neurologist or a general physician to determine the next course of action.
Education and Practicing Optometry
While some countries are laxer in their legal boundaries concerning the practice of optometry, many nations require up-to-date licensing in order to run an optometry practice. In the US individuals must first complete a Doctor of Optometry degree.
This degree program can typically be completed in five years. Upon successful graduation, the candidate must then pass an examination issued by the National Board of Examiners in Optometry or NBEO. This exam is composed of three parts which include basic science, clinical science, and patient care. After passing the exam an optometrist is officially granted the ability to practice optometry, however, there is still more learning to be done. As with any other medical discipline, there are specialties and sub-categories a newly graduated optometrist will be able to explore. This time of exploration is usually undertaken as a residency.
A residency is a brief period of time during which new optometrists are able to explore and experience the various specialties in the vast field of optometry. This is a time to figure out which specialty is most suitable for them. During this period of discovery, candidates shadow established, veteran optometrists of every specialty they can to determine which area they will pursue during their career. Even after an optometrist has chosen a specialty and begun working in their chosen field, the learning process is still not over. In fact, optometrists will spend a lot of their careers learning new skills and staying informed of the advancements that occur in their field to better their ability to treat their patients.
An Optometrist’s Salary Expectations
Starting out, an optometrist can expect to make a salary of anywhere between $40,000 to 43,000 a year. This figure is, of course, at the lower end of the spectrum. After a few years of practicing optometry salary expectations can rise to between $80,000 to $87,000. At the highest end of the spectrum, an optometrist can expect to make around $130,000. The highest paid optometrists are found in metropolitan areas where the demand for optometry practitioners prescribing eyeglasses or contact lenses with blending designs complimenting the natural eye color is much higher than the number of optometrists available.
Taking into consideration the demand for optometrists, the variety of specialties available and the relatively minimal time spent in school, optometry is a very stable career option. Those who enjoy patient care and a constant thirst for knowledge and learning will undoubtedly be satisfied in pursuing optometry.
Vitamin B6 (Pyridoxine) has many health benefits. Scientific evidence shows that vitamin B6 may help prevent coronary heart disease by helping reduce blood levels of the animo acid homocysteine. Studies show B6 is also beneficial in alleviating mood swings and depression, PMS, asthma and fatigue.
Symptoms of Vitamin B6 Deficiency
A deficiency of vitamin B6 is rare as this vitamin is readily available in many food sources. Symptoms of vitamin B6 deficiency may include skin disorders and inflammation of the tongue and mucous membranes of the mouth. In addition, a deficiency of vitamin B6 may cause dizziness, weakness and anemia. Convulsions may also occur, especially in infants.
Vitamin B6 also helps make the neurotransmitters serotonin, norepinephrine and dopamine, which help balance moods. Vitamin B6 has long been known as being beneficial for mood swings and depression. Depression, irritability, and mood swings may be indicative of a deficiency of vitamin B6.
Recommended Daily Allowances and B6-Rich Foods
Vitamin B6 is found in a variety of foods, though most of them contain a low level of this nutrient. The richest food sources of B6 are meats such as beef, liver, pork and poultry. Eggs, peanuts, peas, spinach, walnuts, and wheat germ are also significant sources. Dairy products and most fruits and vegetables contain a small amount of vitamin B6, but are not a rich source.
The Optimal Daily Allowance for vitamin B6 for adults is four to 10 milligrams. While it is possible to get enough vitamin B6 through diet alone, most individuals fail to reach the recommended daily allowance without taking a supplement. The nutrient is generally safe up to 500 milligrams a day. It is important not to take excessive amounts of vitamin B6. Toxicity may cause neurological problems such as skin rash, numbness in the hands and feet and difficulty walking.
Who is at Risk for Vitamin B6 Deficiency?
Certain lifestyle choices, such as drinking or taking oral contraceptives, may affect the amount of vitamin B6 the body is able to absorb.
Individuals who many be at risk of a vitamin B6 deficiency include:
- oral contraceptive users
- heavy drinkers
- pregnant or breast-feeding women
- people on high protein diets
- people taking certain medications such as isoniazid, hydralazine, or penicillamine
Though it is possible to consume the Optimal Daily Allowance of vitamin B6 through diet alone, many people, especially those at risk, might benefit by taking a daily supplement.
Penicillin ,which was the first antibiotic, now joins over 100 antibiotics commonly prescribed to treat bacterial infections. These drugs work to kill and inhibit further growth of bacteria. They are not effective treatment for fighting viruses or fungal infections. Antibiotics are prescribed for bacterial infections and should never be taken for other types of infections. Never save unused antibiotics for later use or take antibiotics that have been prescribed for someone else. Misuse of antibiotics causes serious consequences.
Development of Drug-Resistant Infections
The misuse of antibiotics results in the increased risk of drug-resistant infections. This means that the antibiotic is no longer effective against the disease-causing bacteria. The staff of the Mayo Clinic cite the recent spread of MRSA or methicillin-resistant Staphylococcus aureus. This infection was once confined to hospitalized patients. Now a new strain of the bacteria has become prevalent and has infected healthy people in the general population. Drug-resistant infections are more difficult to treat, have a prolonged course of treatment and raise the cost of health care. Health care costs increase because of the need for more doctor’s visits, possible hospitalization and more expensive and toxic medications. Death is a consequence of certain drug-resistant infections. Antibiotic-resistant bacteria poses a global health treat since infectious bacteria adapt quickly. This presents the challenge to develop new antibiotics and treatments to keep pace with the new strains of bacteria.
Promoting Bacterial Overgrowth
One example of bacterial overgrowth attributed to antibiotic misuse is a new strain of Clostridum difficile. This bacterium causes diarrhea and serious intestinal conditions such as colitis. In 2000, a new clindamycin-resistant strain of Clostridum difficile was responsible for an outbreak of diarrhea in hospitals in the United States. Clostridum difficile diarrhea has long been associated with antibiotic use. Overuse of antibiotics suppresses the normal intestinal bacteria that inhibit the overgrowth of pathogenic microorganisms. According to the staff of the Mayo Clinic, the risk of susceptibility increases with recent use of broad spectrum antibiotics that treat a wide range of bacteria, use of multiple antibiotics and prolonged use. Preventative measures against contracting the illness include proper hand washing and hygiene and avoidance of unnecessary use of antibiotics.
Jeopardizing the Health of Others
Antibiotics should be taken exactly as prescribed by a physician. Never stop taking the medication a few days early simply because you feel better. A full course of antibiotic therapy is the only effective means of killing all of the harmful bacteria. A shortened course destroys only the most vulnerable bacteria and allows the relatively resistant bacteria to survive. Consequently, the infected person spreads the surviving bacteria to other people with whom he comes in contact.
The genus Mycobacterium contains many members, few of which are pathogens. But when pathogenic, chronic diseases such as tuberculosis and Hansen’s Disease may result.
All members of the genus Mycobacterium have special features that make these species resistant to control. Mycobacteria have a unique bacterial cell wall that contains large quantities of a lipid called mycolic acid. This lipid results in a waxy bacterial cell wall that is directly responsible for the control-resistant features of pathogens in this genus.
The presence of mycolic acid also makes it difficult to reliably stain Mycobacteria with water-based stains, such as the Gram stain, used to help identify groups of bacteria. A special stain, called the acid-fast stain, must be used to identify Mycobacteria. This staining protocol employs heat to permanently drive a pink dye into the waxy cell wall.
The Chronic Nature of Mycobacterial Diseases
Mycobacterial diseases are chronic, developing slowly due to relatively long generation time of these bacteria. Generation time is how long it takes for a bacterial population to double, as individual bacteria divide by binary fission. Whereas it only takes Escherichia coli, a nonacid-fast bacterium, a matter of minutes to double its population, Mycobacterial generation time varies from hours to days.
Pathogenicity of Mycobacteria
The waxy cell wall also protects this type of bacteria from osmotic effects and many antibiotics. Mycobacteria are one of the few bacteria types that are capable of intracellular growth (multiplying within an animal cell); and when engulfed by phagocytic cells of the immune system, Mycobacteria are resistant to degradation by digestive enzymes of these phagocytes.
Tuberculosis Caused by Mycobacteria
Caused mainly by the bacterium Mycobacterium tuberculosis, TB (also known as Tubercle bacillus) is an infectious disease of the respiratory system that can ultimately disseminate from the lungs and result in a body-wide, systemic infection. The waxy cell wall of M. tuberculosis enables the bacteria to remain viable, in dried aerosol droplets, for up to 8 months. Only a small percentage of people infected with this bacterium will develop the disease, but it only takes one bacterium to infect, and left untreated, active TB results in a mortality rate of approximately 50%.
Those in the medical field, and others with a high risk of contracting TB, are routinely tested with the Mantoux test or the tuberculin skin test (TST). The TST involves injection of a very small amount of a purified protein derivative or tuberculin into the inner part of the lower arm. Testing positive does not, however, indicate a definite infection with TB. False positive TB test results are common and require follow up diagnostics.
Leprosy Caused by Mycobacteria
Also known as Hansen’s disease, this dreaded infection is caused by M. leprae. This unusual bacterium grows best in a climate lower than body temperature, a preference evidenced by the peripheral locations on the human body (fingers, toes, lips, earlobes) where the bacteria is most prone to thrive.
The disease manifests in one two forms. Those who only develop the nonprogessive form, called tuberculoid leprosy, have a strong immune response to the bacteria that is able to kill the body cells infected with M. leprae. Individuals with a weak cell-mediated immune response develop the more well-known form of the disease, lepromatous leprosy, which disfigures by slowly destroying infected tissues.
Those infected, who have access to medical care, typically aren’t diagnosed until they display desensitized lesions or disfigurement. At that point, a skin test, similar to that for tuberculosis, is done.
Treatment of Tuberculosis and Leprosy
Pathogenic Mycobacteria are inherently resistant to eradication, due to the protection derived from the mycolic acid. This genera also is quick to develop resistance to antimicrobial medication. Multi-drug therapy is required to eliminate, or sometimes only control, infection.
Tuberculosis is a worldwide public health problem and prevention and treatment are necessary to control it.
The three worst public health problems in the world today are malaria, tuberculosis, and human immunodeficiency virus infection. Human immunodeficiency virus infection is the strongest risk factor for the development of active tuberculosis. Should the two diseases occur together, they each worsen the clinical course of the other. More than one-third of the world’s population today has tuberculosis.
One hundred years ago, tuberculosis and other infectious ailments were the leading causes of death in the world. In the mid-twentieth century, the development of drugs to treat tuberculosis significantly brought the disease under control. Institutionalized patients who had been contagious for years were no longer capable of spreading tuberculosis to others, and they were able to return to the community.
Over the last few decades, however, the HIV/AIDS epidemic changed the management of this disease.
In essence, there has been a resurgence of tuberculosis because of HIV/AIDS. Worldwide, nine million people acquire tuberculosis each year, and two million deaths from the disease occur yearly. Moreover, there are problems with resistance to anti-tuberculous medications. Specifically, there is multi-drug resistance in which more than one of the agents to treat tuberculosis are not effective.
In Russia, Latvia, South Africa, the United States, and other countries, there are cases of extensively drug resistant tuberculosis, which are quite deadly not only for the patients, but also for the health care staff who manage them.
Groups at risk
Aside from those who are HIV-positive, several other groups of people are at risk for the acquisition of tuberculosis. These include elderly people, infants and small children, injection drug users, and patients with chronic diseases, which impair the immune system such as diabetes and cancer. Patients who are underweight have a predisposition for tuberculosis, and individuals who take long-term steroid therapy are capable of activation of latent tuberculosis.
Anyone who has had tuberculosis during the last two years may experience a recurrence of the disease, and patients whose tuberculosis did not receive adequate treatment will be at risk for it again.
Signs and symptoms of tuberculosis include weakness, coughing blood, weight loss, night sweats, chest pain, and fever. If a person has these symptoms or has spent time around someone who has tuberculosis, he or she must visit a physician or local health department for evaluation. Tuberculosis transmits from one person to another via the air.
In other words, an individual with active tuberculosis can spread the disease to someone else when he or she coughs, speaks, laughs, sneezes, or sings. It does not transmit through hand shakes, kissing, contact with linens or toilet seats, or sharing food or drinks.
If one has exposure to the bacterium which causes tuberculosis, he or she will not necessarily develop active disease. Their tuberculin skin test may become positive, but they may spend the rest of their lives without ever becoming contagious. Active tuberculosis, however, is contagious and requires the use of several drugs over a period of nearly one year. The duration of therapy and the choice of drugs will depend on the individual patient’s condition.
Tuberculosis and pregnancy
Anti-tuberculous agents are necessary for pregnant women who have the disease. Although some of the drugs, such as streptomycin and pyrazinamide, may not be safe for the fetus, other agents, such as isoniazid, ethambutol, and rifampin, are available which do not appear to pose a problem for the baby. The baby is at risk for low birth weight if the mother does not take medication for tuberculosis during pregnancy.
Mothers who are HIV-positive can take pyrazinamide during pregnancy because the benefits of the drug for these patients outweigh its risks.
There is no reason why a mother who takes anti-tuberculous medication cannot breastfeed her child. Small amounts of these medications are present in breast milk, but there is no evidence that this is unsafe for the infant. If the mother takes isoniazid while she breastfeeds, she should also take vitamin B6 supplementation.