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Peritonitis is defined as an inflammation of the serous membranes of the peritoneal cavity. It may be a primary disease or secondary to other pathologic conditions. Different infectious and noninfectious agents may cause peritonitis, which may result in a variety of clinical manifestations, disease progression, and outcome. Peritonitis may be acute or chronic, septic or nonseptic, local or diffuse, or adhesive or exudative. The term "tertiary peritonitis," used in human medicine for particular cases of chronic peritonitis with a small number of bacteria or fungi, is not used in veterinary medicine.
Etiology of Peritonitis in Animals
Primary peritonitis is less common than secondary peritonitis and may be infectious or idiopathic. In infectious primary peritonitis, infectious agents spread via the bloodstream into the peritoneal cavity of animals that are often immunocompromised. Such infectious agents include feline coronavirus (FCoV), which causes feline infectious peritonitis Feline Infectious Peritonitis Feline infectious peritonitis is a severe, immune-mediated coronaviral disease of cats. Effusion and pyogranulomatous inflammation are clinical hallmarks. Diagnosis requires a multimodal approach... read more (FIP); Nocardia spp; Mycobacterium spp; Haemophilus parasuis; and other infectious agents. Progression of primary peritonitis tends to be chronic.
Peritonitis occurs secondary to another disease as the result of exposure of the peritoneal cavity to nonspecific infectious or noninfectious agents. It is often acute and frequently results in a progressive, systemic disease. Secondary septic peritonitis is commonly associated with perforation of and leakage from GI organs (eg, traumatic reticuloperitonitis in cattle), with subsequent processes allowing transmural migration of bacteria (eg, neoplasia, intestinal ischemia), or with perforation/rupture of or leakage from other infected viscera (eg, abscesses in liver, spleen, omentum, cystitis, endometritis, pyometra). Furthermore, migration of parasites through the abdominal cavity may also result in leakage of chyme with subsequent septic peritonitis. Perforating wounds of the abdominal wall (eg, dog bites) or dehiscence of abdominal wound closure may result in laceration of viscera and inoculation of foreign material and microorganisms into the peritoneal cavity.
Microorganisms associated with septic peritonitis usually reflect the source of contamination. A mixed bacterial population is seen in GI tract perforation, whereas perforation of nongastrointestinal viscera (eg, urinary or gall bladder, uterus, prostate) or hematogenous infection of the peritoneal cavity may be more typically associated with aerobic organisms, including Escherichia coli, Streptococcus equi zooepidemicus, Staphylococcus, Proteus, Rhodococcus, Klebsiella, Salmonella, Enterobacter, Pseudomonas, or Corynebacterium.
Secondary aseptic peritonitis occurs after contamination of the abdominal cavity with chemical irritants (eg, bile, urine, drugs) or intestinal ischemia. Common conditions are urolithiasis and rupture of the urinary or gall bladder; however, these conditions are not always aseptic. The originally aseptic peritoneal inflammations may later become septic. In addition, intraperitoneal administration of drugs or fluids may result in temporary inflammatory reactions of the peritoneum. Because New World camelids show severe inflammatory reactions to infections with Dicrocoelium dendriticum, peritonitis may develop subsequent to the severe hepatitis. In large animals, peritonitis is most commonly seen in cattle, less often in horses, and rarely diagnosed in pigs, sheep, and goats. It is a serious and often fatal condition in cats (FIP). For common causes of peritonitis in various species, see Table: Common Causes of Peritonitis Common Causes of Peritonitis .
Pathogenesis of Peritonitis in Animals
Inflammation of the peritoneum is the result of a variety of possible pathogenetic pathways that are species-dependent (eg, peritoneal inflammatory response in cattle is characterized by extensive fibrin formation, horses tend to develop exudative peritonitis) and mainly influenced by etiology (eg, primary or secondary, septic or nonseptic). Because of the release of inflammatory mediators after contact with mechanical, chemical, or infectious agents, serosal capillary permeability is increased and results in leakage of plasma proteins, solutes, and water into the peritoneal cavity. Exudation of protein-rich fluid may result in hypoproteinemia and facilitates bacterial proliferation. The combined effect of large fluid losses into the peritoneal cavity and vasodilatory effects of absorbed toxins may produce profound hypotension and hypovolemia. The inflammation may decrease the animal's antioxidative capacity and result in oxidative stress.
Rupture or perforation of the forestomach, stomach, or intestine with spillage of large volumes of gastric or intestinal contents and rupture or perforation of the contaminated uterus leads to an acute septic peritonitis. Toxins produced by bacteria and tissue breakdown are readily absorbed through the peritoneum and have severe systemic effects leading to hypotension, shock, systemic inflammatory response syndrome (SIRS), and DIC. Endotoxins and acid-base and electrolyte disturbances directly affect cardiac function, leading to reduced cardiac output and circulatory failure. Paralytic ileus is considered to be a frequent result of acute peritonitis, causing functional obstruction and an increased mortality rate.
Large volumes of inflammatory exudates may be secreted into the peritoneal cavity during peritonitis and may lead to impaired respiration by impinging on the diaphragm. Spillage of small amounts of gastric or intestinal content (eg, after transcutaneous rumenocentesis, bar suture techniques for left displaced abomasum surgery) normally result in local peritonitis.
Chronic peritonitis is often characterized by extensive secretion of fibrinogen and subsequent formation of fibrinous/fibrous adhesions. Such adhesions help localize the inflammatory process (eg, traumatic reticuloperitonitis Traumatic Reticuloperitonitis in Cattle Traumatic reticuloperitonitis of cattle occurs when animals ingest nails, pieces of wire, and other nonmetallic materials that injure the reticular wall. Sharp objects can puncture the reticulum... read more in cattle, type 3 abomasal ulcers Abomasal Ulcers in Cattle Abomasal ulcers affect mature cattle and calves and have several different manifestations. Common clinical signs include anorexia, bruxism, abdominal pain, occult blood in the feces, and tachycardia... read more in cattle) but may cause mechanical or functional obstruction of the GI tract. Chronic peritonitis in horses often results in recurrent colic Overview of Colic in Horses Depiction of a horse's GI tract as viewed from the right side. In its strictest definition, the term "colic" means abdominal pain. Throughout the years, it has become a broad term for a variety... read more episodes.
Clinical Findings of Peritonitis in Animals
Clinical signs vary depending on the type and etiology of peritonitis. Affected animals may develop:
increased abdominal wall tension
decreased general behavior and feed intake
abdominal pain/pain reaction when palpated
abdominal fluid accumulation
paralytic ileus
toxemia and septicemia
shock, SIRS
in prolonged cases, adhesions of varying degrees
Shock, hypotension, acid-base disturbances, and circulatory collapse after acute septic peritonitis associated with rupture of intestines or uterus often lead to sudden death. These animals normally show only limited clinical signs of peritonitis. In less severe cases, abdominal pain and fever are common. Hypothermia can also be seen as a result of dehydration, hypovolemia, and sepsis. Abdominal pain may be permanent and severe, characterized by guarding the abdomen, stiff gait, or recumbency. In all species, pain responses are most evident in the early stages. Abdominal distention, which may be inapparent, usually is due to accumulation of peritoneal exudates, paralytic ileus, or peritoneal adhesions. Fecal output is often decreased, although frequency of defecation may be increased in the early stages of peritonitis. Animals with secondary peritonitis may also show clinical signs associated with the primary disease. However, there are reports of apparently clinically healthy animals having chronic bacterial peritonitis.
Rectal palpation is a useful diagnostic technique to evaluate the peritoneum and accessible abdominal organs in large animals; however, local peritonitic processes in the cranial abdomen (eg, traumatic reticuloperitonitis in cattle) do not result in clinical signs that can be diagnosed by rectal examination.
Abdominal radiography Radiography of Animals Radiography (generation of transmission planar images) is one of the most commonly used diagnostic tools in veterinary practice even though other imaging modalities such as ultrasonography,... read more may be used in small animals. In horses and cattle, radiography can be also used as a diagnostic tool, but high-power x-ray machines are required; therefore, this technique is limited to stationary units in veterinary clinics.
Generally, ultrasonography Ultrasonography in Animals Ultrasonography is the second most commonly used imaging format in veterinary practice. It uses ultrasonic sound waves in the frequency range of 1.5–15 megahertz (MHz) to create images of body... read more is the most valuable diagnostic tool to examine the abdominal cavity and assess the extent, localization, and character of peritonitis. Additionally, ultrasonography allows a guided abdominocentesis, which can be used (in both large and small animals) to obtain fluid for cytologic and biochemical examination and bacteriologic culture. Diagnostic peritoneal lavage can be used if peritoneal fluid cannot be obtained by abdominocentesis.
Diagnostic laparoscopy or laparotomy can be considered to verify the diagnosis. Diagnostic laparotomy is frequently used in cattle because it is inexpensive, can be performed in standing position, and is associated with few or minor complications; it also makes additional diagnostic procedures unnecessary and can often be combined with therapeutic measures.
Clinical signs of peritonitis in cattle are often nonspecific and characterized by reduced feed intake, drop in milk production, and decreased rumination activity. In chronic cases, ruminal contractions may be present but reduced in intensity. Abdominal percussion may reveal ruminal tympany or pneumoperitoneum. Moderate fever is typical during the first 24–36 hours in cattle with acute, local peritonitis. High fever suggests acute, diffuse peritonitis. Cattle with peritonitis often have a shuffling, cautious gait with a rigid arched back, and grunt when walking or passing urine or feces. Deep palpation of the abdominal wall and pain provocation tests result in pain response. Calves with peritonitis caused by a perforated abomasal ulcer show a fast deterioration of general condition and clinical signs indicating sepsis and SIRS.
Chronic peritonitis is associated with development of fibrous adhesions. Depending on localization, rectal palpation may reveal adhesions between intestinal loops and peritoneum. Cattle may suffer from chronic indigestion (Hoflund syndrome, abomasal impaction) or toxemia, with periods of acute, severe illness caused by partial intestinal obstruction. The majority of cattle develop a localized peritonitis by extensive fibrin formation; however, in a few cases the abdominal cavity contains large volumes of turbid, infected peritoneal fluid.
Small Ruminants, New World Camelids, and Pigs
Generally, the clinical signs in small ruminants, New World camelids, and pigs are similar to those in other animals. However, peritonitis is rarely diagnosed clinically in pigs, sheep, or goats, although it is not an uncommon finding on routine meat inspection after slaughter of pigs. It is more common in llamas and alpacas, in which trematodes (liver flukes, eg, Fasciola, Dicrocoelium) are the cause.
Clinical signs include colic Overview of Colic in Horses Depiction of a horse's GI tract as viewed from the right side. In its strictest definition, the term "colic" means abdominal pain. Throughout the years, it has become a broad term for a variety... read more , distended intestines on rectal examination, gastric reflux, and occasionally diarrhea. Rectal palpation may reveal tacky, dry mucosa and in some cases fibrinous or fibrous adhesions between intestinal loops and other abdominal organs. Intestinal peristaltic sounds are reduced. Tachycardia, weak pulses, poor peripheral perfusion, and fever are common. Weight loss and intermittent abdominal pain (colic) may be seen in horses with chronic peritonitis.
Dogs and Cats
In small animals, anorexia and depression are nonspecific signs of peritonitis, often accompanied by vomiting and decreased defecation. The abdomen may be distended. Abdominal palpation may be painful, and abdominal masses may be detected. Icterus may be present in generalized biliary peritonitis in small animals. Abdominal radiographs may reveal GI obstruction, bowel dilatation, free abdominal air, ascites, or radiodense foreign material. Loss of serosal details in radiographs indicates abdominal fluid.
Diagnosis of Peritonitis in Animals
Physical examination
Abdominal ultrasonography
Lab analyses
Primarily, diagnosis of peritonitis is based on physical examination, which shows the clinical signs mentioned above. However, advanced diagnostic procedures, especially abdominal ultrasonography, help to verify the diagnosis, visualize the extent and character of the peritonitis, and may provide information on the etiology. Additionally, laboratory analyses are recommended to verify the diagnosis but especially to aid treatment decisions.
Laboratory analyses are helpful to confirm the clinical diagnosis and determine the severity of peritonitis, and should include a CBC and several biochemical parameters in blood and peritoneal fluid.
Acute, diffuse peritonitis with toxemia is usually accompanied by leukopenia, neutropenia, and a marked increase in immature neutrophils (degenerative left shift). In less severe acute peritonitis, leukocytosis may occur as a result of increased neutrophil production. Acute, localized peritonitis may reveal a normal WBC count with a regenerative left shift. The total WBC count in chronic peritonitis may be normal, with an occasional increase in lymphocytes and monocytes. Anemia Anemia in Animals Anemia is an absolute decrease in RBC numbers, hemoglobin concentration, or PCV. Signs include pale mucous membranes, increased heart rate, and hypotension. Diagnosis can be made by CBC, but... read more may occur due to hemorrhage into the peritoneal cavity but is also commonly associated with chronic inflammatory processes. A number of abnormalities of serum biochemical parameters (eg, total protein, albumin, fibrinogen, bilirubin, LDH, alkaline phosphatase, CK) may accompany peritonitis. Hypoalbuminemia, hyperglobulinemia, and hyperbilirubinemia are frequently present. Generally, the changes in hematologic and biochemical parameters indicate inflammatory processes and tissue damage, but they are not pathognomonic for peritonitis.
The peritoneal fluid is a plasma dialysate with specific physical and chemical properties that depend on membrane permeability, concentrations and electrical charges of ions, and osmotic pressure. The fluid contains cells deriving from the mesothelium and the blood or lymphatic vessels. Under physiologic conditions, peritoneal fluid is a transudate, whereas peritonitis results in a fluid that is typically characterized as an exudate. Analysis of peritoneal fluid is a useful diagnostic method in gastroenterology, because the fluid generally reflects abdominal conditions. The volume of peritoneal fluid is frequently increased in peritonitis. In cases of septic peritonitis, samples of peritoneal fluid should be examined microbiologically to characterize infectious pathogens.
The parameters of the classic transudate-exudate categorization system are shown in (Characteristics of Transudates and Exudates in Cattle, Horses, Dogs, and Cats Characteristics of Transudates and Exudates in Cattle, Horses, Dogs, and Cats ). A peritoneal fluid showing properties of both a transudate and an exudate is commonly called a modified transudate. Use of a scoring system allows further classification as mild, moderate, or severe peritonitis. In practice, however, analysis of peritoneal fluid may be inconsistent, leading to inconclusive results. Therefore, the diagnostic value of this traditional concept is limited. To improve the sensitivity of the distinction between an exudate and transudate of pleural and peritoneal effusions in human medicine, Light's criteria (fluid to serum protein ratio >0.5, fluid to serum LDH ratio >0.6, or fluid LDH activity >200 U/L), cutoff values for ratios between peritoneal fluid and plasma or serum of various parameters (eg, lactate, glucose, enzymes), and the serum-ascites albumin gradient (SAAG) have been established. These concepts have been applied to some animal species (ie, horses, cattle, small animals).
Under physiologic conditions, the ratio between lymphocytes and neutrophils is close to 1:1. Acute peritonitis usually results in an increased number of leukocytes, and the percentage of neutrophils can be 60%–90%. However, in cases of peracute septic inflammation, the number of leukocytes may decrease due to necrosis and cell damage. Histologically, a high rate of degenerative leukocytes (cytolysis, karyorrhexis, or karyolysis) can be found. In chronic peritoneal inflammation, the proportion of neutrophils decreases and the proportion of monocytes increases. The presence of intra- or extracellular bacteria confirms septic peritonitis. Gram-staining enables differentiation between gram-positive and gram-negative bacteria and facilitates early antibiotic treatment.
The physiologic total protein concentration in peritoneal fluid is 20–25 g/L. The normal protein ratio between peritoneal fluid and serum is lower than 1:2. The SAAG is calculated by subtracting the peritoneal fluid albumin concentration from the serum concentration. The cutoff value of 11 g/L for people seems suitable for monogastric animals. However, the reference values for protein ratio and SAAG are not applicable to dairy cattle, mainly because of their higher serum protein and albumin concentrations than those of monogastric animals and people. In addition, in cattle, the protein ratio and SAAG did not show higher diagnostic values than the total protein concentration in peritoneal fluid alone.
In healthy animals, glucose concentration is the same in both serum and peritoneal fluid. Bacterial infection of the peritoneal cavity results in a major decrease of peritoneal glucose concentration. A peritoneal fluid:serum ratio of glucose concentrations <0.5 is highly sensitive and specific for septic peritonitis. Because in animals with septic peritonitis the glucose concentration in peritoneal fluid frequently falls below the detection limit, it is often not even necessary to measure the glucose concentration in serum.
Intestinal ischemia results in an increase of l-lactate concentration in plasma and peritoneal fluid. Although an association exists between l-lactate concentration in peritoneal fluid and plasma, l-lactate in peritoneal fluid is considered to be more closely correlated to the severity of intestinal ischemia. Physiologically, l-lactate concentration in peritoneal fluid is lower than that in plasma (in healthy horses, the ratio is ~1:2). This ratio is reversed in colicky horses with intestinal ischemia, cows with abomasal volvulus, and dogs with gastric dilatation volvulus. Similar to that in horses, an increased l-lactate concentration in peritoneal fluid has been found in cattle with abomasal volvulus and dogs with gastric dilatation volvulus. In addition, lactate is also a bacterial metabolite (predominately d-lactate); therefore, increased lactate concentration in peritoneal fluid may also indicate septic peritonitis. The accuracy of peritoneal lactate concentration in differentiating septic and nonseptic peritonitis varies between species (eg, 90%–95% in dogs but 65%–70% in cats).
Inflammation can be monitored using acute phase proteins such as C-reactive protein or haptoglobin (in cattle) as markers. Acute phase protein concentrations are increased in peripheral blood and in peritoneal fluid in animals with peritonitis; however, these parameters are general indicators for inflammation and not specific for peritonitis.
Fibrinogen concentration in peritoneal fluid may be increased in animals with peritonitis. However, fibrinogen concentration has limited diagnostic value, because there is only a weak association between peritoneal and blood fibrinogen concentration. An increased concentration of the fibrin degradation product d-dimer indicates intestinal ischemia and inflammation with high sensitivity and specificity. Normal values for human plasma are <0.3 mg/L. Reference values for small animals and horses seem to be similar to those in people. The peritoneal fluid d-dimer concentration in healthy cows is <0.6 mg/L; increased values indicate peritonitis with high sensitivity and specificity.
Inflammation, intestinal ischemia, and reperfusion affect the activities of several enzymes (alkaline phosphatase [ALP], AST, CK, LDH) in peritoneal fluid and peripheral blood. CK activity is primarily increased in serum and peritoneal fluid in cases of intestinal ischemia. The origin of CK is thought to be the muscular layer of the strangulated, ischemic intestines. However, other tissues (eg, striated muscle after colic episodes in horses) may be sources of higher CK activities; therefore, the sensitivity and specificity of CK are low.
LDH activity is a measure of inflammatory response and has been used to differentiate exudate from transudate (peritoneal fluid:serum LDH ratio >0.6; LDH activity of peritoneal fluid >200 U/L). The reference values for monogastric animals, but not those for cattle, are similar to those for people. For cattle, a cut-off value of 960 U/L has been identified.
An increase of ALP during intestinal ischemia and reperfusion has been found in peritoneal fluid of horses with colic and cows with displaced abomasum. However, the origin of the ALP was not exclusively the damaged stomach or intestine. Other sources of the increased ALP activity in these cases include hepatocytes and granulocytes. Normally, serum ALP activity does not show major changes during intestinal ischemia.
Increased concentrations of protein and globulin in serum and peritoneal fluid are often seen in cats with FIP. However, neither parameter is accurate enough for diagnosis, especially if measured in serum. Calculation of the albumin:globulin ratio may improve the diagnostic value. The traditional Rivalta's test simply differentiates transudates from exudates. Although it produces false-positive results in cats with septic bacterial peritonitis, it still seems useful for FIP diagnosis. The widely used parameter alpha-1-acid glycoprotein indicates inflammation but is not specific for FIP.
Serum anti-feline coronavirus (FCoV) antibody titers must be interpreted critically, because many healthy cats are anti-FCoV-antibody positive. The diagnostic value of anti-FCoV antibody titers in peritoneal fluid is still under discussion. A number of advanced diagnostic methods (eg, immunofluorescent staining of FCoV antigen in peritoneal macrophages, ELISA to detect antigen-antibody complexes in serum, reverse transcriptase-PCR) have been introduced as diagnostic measures to improve accuracy of FIP diagnosis. Generally, the laboratory tests performed on peritoneal fluid are superior to those that use serum. Further immunohistochemistry for intracellular FCoV antigen in macrophages derived from ocular or dermal lesions of FIP cats may aid the diagnosis. (Also see Feline Infectious Peritonitis Feline Infectious Peritonitis .)
Prognosis of Peritonitis in Animals
Although the mesothelium of the peritoneum is able to regenerate rapidly, peritonitis must be considered a severe, life-threatening disease with a guarded prognosis. Prognosis strongly depends on the character and severity of the disease and, therefore, must be determined individually. General survival rates of 50%–70% have been reported, with much lower rates for return of productivity in farm animals. In horses, the prognosis for further use in equestrian sport is guarded. Furthermore, horses that survive peritonitis frequently suffer from recurrent colic episodes. Despite new developments in therapy, the prognosis for cats with FIP remains poor. It is still a lethal disease with no effective long-term treatment.
Treatment of Peritonitis in Animals
May include peritoneal lavage, surgery, antibiotics, and anti-inflammatory medications
Adequate therapy for peritonitis depends on the diagnosis and the results of physical examination and laboratory analyses. In severe cases of septic peritonitis, the initial treatment must be directed toward saving the life of the animal and stabilizing cardiovascular and other organ functions. In severe cases, euthanasia is a consideration. Therapy should include treatment of hypovolemic/toxemic shock, aggressive anti-inflammatory therapy, and treatment of the metabolic and rheologic disturbances (eg, electrolyte and acid-base disorders, DIC). Replacement fluids, electrolytes, plasma, or whole blood may be necessary to maintain cardiac output and improve circulation. It is of major importance to prevent circulatory failure from complications of DIC. Antioxidative treatment using vitamins C and E or short-acting glucocorticoids might be useful. Additional prokinetic drugs might be necessary to increase and coordinate the motility of the GI tract.
Appropriate antimicrobial therapy should be started once septic peritonitis is suspected or confirmed. Peritoneal fluid samples should be obtained for culture and sensitivity testing. Parenteral broad-spectrum antimicrobial therapy must be applied initially. Aminoglycoside or fluoroquinolone antibiotics are effective against gram-negative organisms, and penicillins or cephalosporins are effective against gram-positive bacteria. The antimicrobial drug may be changed later according to the results of cytology and culture and sensitivity testing. Antimicrobial and anti-inflammatory treatment should continue through the healing period.
If possible, therapy should be initiated to eliminate the cause of peritonitis. In animals with suspected leakage of abdominal organs, surgery should be performed immediately to explore the abdomen and repair the defects, followed by peritoneal lavage with an isothermic, isotonic, balanced electrolyte solution before the abdominal cavity is closed. Although frequently performed, there is no proven clinical benefit in adding antimicrobial drugs to the lavage solution. Solutions containing antiseptics (eg, povidone-iodine) also have no proven clinical benefit and may even function as chemical irritants and exacerbate the inflammation. Heparin treatment may be considered in cases of DIC and may prevent extensive fibrin formation within the peritoneal cavity.
The application of abdominal drains and subsequent lavage is possible in small and large animals to treat severe peritonitis, removing septic and proinflammatory material from the abdominal cavity. Whereas the removal of septic peritoneal fluid is generally accepted as beneficial, the efficacy of repeated peritoneal lavage is under debate. Whereas some reports describe positive effects, others claim that intensive lavage may disturb healing of the epithelium and result in further spread of the inflammation. The composition of the lavage solution is also under debate; there are no or very few advantages to adding antibiotics or antiseptics.
The decision to manage peritoneal drainage is based on the severity of the case, experience level, intensive care possibility, and equipment. Maintenance of drain patency can be difficult, especially in cattle, caused by the extensive fibrin formation in the abdominal cavity. In animals treated by peritoneal drainage or lavage, serum protein and electrolyte levels should be monitored periodically, because both are lost with drainage of exudate.
Nutritional support should be anticipated, because many animals with peritonitis will not eat. Enteral nutrition helps to maintain the health of the intestinal mucosa; however, vomiting (dogs and cats) or anorexia may force the consideration of alternatives. In ruminants and New World camelids, transfaunation using rumen fluid obtained from other animals or commercially available products has proved beneficial. In certain animals, total or partial parenteral nutrition may be necessary to provide a portion of the nutritional requirements while enteral nutrition is being initiated. Administration of antioxidants and vitamins should be considered. Vomiting is sometimes a sequela of peritonitis in small animals; antiemetic treatment is indicated in such cases.
Feline coronaviral infection may cause a primary FIP. Therapy is palliative (eg, interferon therapy, glucocorticoids, supportive therapy) and directed toward slowing down the inflammation. However, no effective long-term therapy is available. Commercial vaccines for prophylaxis are available in some countries; however, there are conflicting reports on their efficacy and safety. The vaccine is not effective when administered to animals already exposed to FCoV; however, it may offer some protection when administered to seronegative animals.
In chronic adhesive peritonitis, laparoscopy or laparotomy may be considered to cut adhesions that prevent intestinal motility or to remove/drain intestinal abscesses. However, the success of such interventions might be limited.
Key Points
Acute peritonitis is frequently a severe, life-threatening condition.
Diagnostic procedures are directed to determine the etiology and character of the peritonitis.
Aggressive treatment is often required.
Animals with chronic peritonitis may show disturbed GI motility with recurrent signs of colic.
For More Information
Also see pet health content regarding peritonitis in cats Peritonitis in Cats Peritonitis is inflammation of the peritoneum, the membrane that lines the abdominal cavity. It is a serious and often fatal condition. Peritonitis may be short- or longterm, localized or widespread... read more and dogs Peritonitis in Dogs Peritonitis is inflammation of the membrane that lines the inside of the abdominal cavity (peritoneum). It is a serious and often fatal condition in dogs, with mortality ranging from 50% to... read more .


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Goldschlager® Standard Hookah White w/1 Hose
This is a Quality Handmade Hookah – Shisha
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If You Don't See The Bottle Hookah Your Looking for – We Can Make Just About Any Bottle Into A Hookah Or Water Pipe For You!
Trademarks on bottles belong to and are property of the company in which they represent.
* The Hose and Bowl Colors may vary slightly based on availability & supply.
The upcycled, and handcrafted products sold here in Bottle Heaven have no mutual affiliations, sponsorships, or endorsements with the companies who produce, and/or resell original bottles in original form. *See Policies and Procedures Page for more details.


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Islam Ibrahim has no idea if his older brother Nasim was one of the Republican Guardsmen shooting at him when he and hundreds of other Egyptians were wounded and more than 50 killed.
The brothers, who moved together to Cairo from a village near the Suez Canal, stayed close until last week, when the army in which Nasim serves toppled the president that Islam has vowed to defend.
"I don't know if he was there with them or not," said Islam, 24, with a bandage from a gunshot on his knee and an open wound from birdshot on his shoulder.
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"I don't like to think about it. If he was, I know he wouldn't fire on unarmed demonstrators," he said. He sat on a plastic chair behind the stage at the camp near a Cairo mosque where thousands of supporters of the deposed president, Mohamed Morsi, say they will keep a protest vigil until he is restored.
The overthrow of Morsi, Egypt's first democratically elected president, has split the country like no other event in memory, dividing brothers from brothers, fathers from sons and husbands from wives.
Video courtesy of jn1.tv
Two days after the army ousted Morsi following escalating street protests against his rule, Islam called his brother to invite him to a pro-Morsi rally.
"He said I should be at home celebrating and that the army had saved the country from chaos," recalled Islam. The brothers have not spoken since.
A few days later, Islam was among protesters outside the headquarters of his brother's Republican Guard when they were fired upon in one of the deadliest incidents in more than two years of political unrest.
"I was still praying when I heard the gunfire. I was 300 meters away from the soldiers. They were shooting teargas over our heads," said Islam, clutching a walking cane in one hand and a Koran in a brown leather case in the other.
"I heard bullets flying in all directions. Everyone was running left and right. Some of my friends were throwing rocks at the soldiers. We made a shield out of steel traffic barriers, but my leg was sticking out and a bullet struck me in the knee.
"My friend helped me stop the bleeding with his shirt. As I was running back another bullet hit me in the shoulder."
The army says the violence was provoked by terrorists who attacked its troops. The Brotherhood says its supporters were fired upon while peacefully praying. Footage circulated widely on the Internet shows uniformed snipers firing from rooftops.
The most chilling of those videos was filmed by Ahmed Assem, a baby-faced 26-year-old photographer for a Muslim Brotherhood newspaper. The footage shows a sniper shooting off to one side, then suddenly turning straight towards the photographer and firing. Assem's camera blacks out at the moment of impact from the shot that killed him.
Assem too came from a divided family: he was the only Morsi supporter in a household raised to despise the Brotherhood.
His father Samir Assem, a doctor, is furious that the Brotherhood has declared his son a martyr: "Trading in blood. Trading in blood," he says angrily.
The slain photographer's older brother Eslam, who picked up the body at the morgue on Monday, is a captain in the police. Photos in a frame at the family home show the two men, the younger smiling in a button-down shirt, the older standing proudly in his dress uniform.
The brothers occasionally used to chide each other about their allegiances, said Eslam.
"I would speak to him, like any two brothers," he recalled at the family home in a middle-class Cairo district. "'Leave the Muslim Brotherhood.' 'No, you leave the Ministry of Interior.'"
They stayed close despite the disputes: "He is my brother. That's the only thing. He is my brother. He is working in the newspaper. I am working in the Ministry of the Interior. But the last thing is: he is my brother."
Eslam has no doubt that the video his brother filmed shows he was an innocent victim of a deliberate killing by a soldier who picked him out of the crowd.
"His only crime is that he is recording a video. He has no gun, no pistol, no nothing in his hand, but a camera," he said. He plans to report the killing to prosecutors, to try to bring the soldier who killed his brother to justice.
But his brother's death has not shaken his hatred for the Brotherhood: "The Muslim Brotherhood leaders are devils," he said. "None of the kids who died were the children of the leaders of the Muslim Brotherhood. It's never their sons who are being sent into the line of fire."
Back at the tent at the Brotherhood camp, Islam Ibrahim tells of how close he and his soldier brother were when they moved to Cairo three years ago. Nasim was sent to the capital to serve in the Republican Guard; Islam found a job teaching Arabic at a mosque.
Their father, head of a tourism company, had been a member of the Brotherhood in the 1980s and 90s who quit after he was arrested and tortured by autocrat Hosni Mubarak's secret police. Islam joined the Brotherhood at 18 after he heard a sermon from a preacher from Alexandria. He revealed his membership to his father but kept it from his mother so she would not worry.
The brothers' politics overlapped during the 2011 revolution that toppled Mubarak. They attended protests together then, but drifted apart a bit after Mubarak's fall. Islam knew that Nasim disapproved of his ties to the Brotherhood. Still, they had remained on good terms until now.
Today, he cannot imagine how Nasim can remain in an army that toppled an elected president and shot so many people.
"He has to leave the army now. It is no longer possible to support Egypt and support the army. Those two things are incompatible," Islam said.
"I have called him but he doesn't answer his phone."
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WARSAW, Poland (AP) — Poland's national airline LOT welcomed its first Boeing 787 "Dreamliner" into its fleet Thursday, becoming the first European carrier to get the U.S. aircraft maker's newest plane.
The plane has been hailed for a state-of-the art design that makes it more fuel efficient and comfortable for passengers than an earlier generation of aircraft, and many in this ex-communist country celebrated its arrival as a symbolic step in the country's speedy economic and technological development.
The tabloid Fakt declared the plane a "Technical miracle from America" in a front-page headline. "In Europe only Poland has such a super modern airplane," the paper boasted.
LOT has ordered eight in total, with the next four due to be delivered early next year.
Plans for the plane to land in Warsaw escorted by F-16 fighter jets were scrapped due to heavy fog. But the weather didn't stop people from gathering near Warsaw's international airport to get a glimpse of the jet.
The all-news station TVN24 devoted the morning to live coverage of its arrival as if it were a historic event. One couple interviewed by the station had traveled hundreds of kilometers (miles) to see the plane, and described being fascinated and moved.
Boeing delivered the plane to LOT airlines on Wednesday in the U.S. state of Washington, where Boeing's commercial planes division is headquartered. There a Polish priest blessed the plane with holy water. It then made the trans-Atlantic flight with four LOT pilots and two American instructors from Boeing. On the tarmac in Warsaw it was sprayed with water in a "traditional salute," LOT said.
Now it remains to be seen whether the upgrade to LOT's fleet will strengthen the business position of the struggling state-run company. LOT lost money last year, partly due to the high cost of fuel worldwide.
Aside from their fuel efficiency, which will lower operating costs, the Dreamliners could make LOT more attractive to potential investors as the company seeks a majority stakeholder, said Andrzej Halesiak, an economist with Bank Pekao SA in Warsaw who studies the airline industry.
Turkish Airlines had considered buying LOT but earlier this year decided against such a step.
Having Dreamliners before other European airlines could help Warsaw become a regional transit hub for long-range routes to the United States, Canada and China, Halesiak said.
"The Dreamliner can help LOT to become more offensive in its strategy," Halesiak said. "It might attract passengers to LOT airlines."
LOT plans to fly its first Boeing 787 on short-haul flights in December in Europe. Early next year it will fly routes between Poland and New York, Chicago and Toronto.
Boeing says a total of 838 Dreamliners have been ordered worldwide. The company recently started to deliver the jets, with 36 handed over so far, after more than three years of delays.


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Home Medication Review – a structured and collaborative service for multimorbid type 2 diabetic patients provided by community pharmacies and practitioners
Suche in Medline nach
Veröffentlicht: | 22. November 2010 |
Introduction: Inappropriate drug use is a common problem for elderly multimorbid patients. Several studies in different countries (e.g. Australia, Great Britain) showed that Home Medication Reviews (HMR) could improve the health status of elderly people. The aim of this pilot study was to develop tools and to calculate expenditures for a Home Medication Review in Germany.
Methods: The HMR was conducted by 2 pharmacists and 7 physicians (6 general practitioners, 1 cardiologist) from 3 doctor's practices.
- The pharmacists selected patients by diagnose and associated physician out of their database.
- Pharmacist and physician together generated a medication plan. Apart from the medication, this plan also contained clinical data and diagnoses. All prescribed drugs from other physician were included.
- The pharmacist visited patient at home. There he completed the medication plan during his HMR with all (self-) medication and devices, presented by patient. In addition all pills were counted.
- Drug-related problems and questions by patient were documented.
- All outcomes of the HMR were discussed with physician promptly.
- Based on the review of findings, physician and pharmacist designed a management plan with defined responsibilities in concordance with patient. The aim of this plan was an improvement of therapy.
- The pharmacist visited patient again after 6 month to evaluate results.
Results: 47 out of 50 patients (3 drop-outs) were visited two times with complete documentation (mean age 71.7, female 57.4%, male 42.6%, average number of diagnosis 6.8, average number of long term medication 8.8).
10 patients were advised to contact their physicians at once. There was no significant reduction in HbA1c for the whole group (7.8 to 7.7). Those 7 patients with the highest HbA1c (>9) showed a decrease of 0.9 [mean] =9%. The hypoglycaemia symptoms decreased from 57% to 39%. Knowledge and dealing with disease increased. Tools were developed and made available to the public.
Discussion and conclusion: A pharmacy and physician service model for multimorbid type 2 diabetic patients was successfully utilized. The practice research underlines the necessity of HMR as an intervention to increase the safety and efficiency of pharmacotherapy. Stepwise implementation should be realized.


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The Legionarius Alessio Sakara visited AS Roma football team to meet with The Gladiator Francesco Totti and World Cup Winner Daniele De Rossi
Las Vegas, May 11, 2012 Yesterday morning, Alessio "Legionarius" Sakara had the honor of meeting Francesco "Gladiator" Totti and Daniele "Future Captain" De Rossi, two exceptionally talented athletes, at the AS Roma training ground in Trigoria.
Danielle De Rossi, midfielder of AS Roma and Italian National Team player and Alessio Sakara, UFC athlete known as "Legionarius", joked around in front of the video cameras of Roma Channel exchanging ideas about their passion for UFC, global premier organization in the promotion of Mixed Martial Arts.
Francesco Totti and Alessio Sakara
"MMA is a sport that fascinates me", explained De Rossi "Like all contact sports, they are tough but at the roots of combat is a loyalty and respect between the athletes. With Alessio, however, I would only compete against with my playstation", De Rossi continued referring to the UFC video game Undisputed 3, which features Alessio Sakara as a character.
"Behind a sport like MMA there is a physical preparation that is 10 times that of football" - the Roma midfielder continued. "It is a sport where you have to be an athlete that is 100%, its not hard to be submitted by your opponent, so you have to stay focused at all times".
Alessio Sakara and Daniele De Rossi
"Rome is my city and I'm very happy to be here today. When I spoke about Rome however, I don't just mean my city, I mean the whole empire. I am in love with what our ancestors left us and it si thanks to them that Rome is such a popular city today. Roman fighters, Legionarius, are my inspiration because I aim to always have the same determination that they had during battle," Alessio Sakra explained.
During their meet and greet, Sakara and the young footballer exchanged UFC gloves and an AS Roma jersey baring De Rossi's team number.
A meeting between Roman athletes that pride themselves of an ever growing stars and stripes background. Infact, AS Roma has recently been pruchased by the American Thomas DiBenedetto, born in Boston with Italian origins. This summer, AS Roma will be visiting Boston, Chicago, and New York with a series of friendly matches.
UFC Performance Institute
Dana White On The Opening Of UFC PI Mexico


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The University of Hawaii at Hilo honored four faculty and staff members for their dedication and extraordinary contributions to the university.
Chancellor Donald Straney presented the Award for Excellence in Scholarly/Creative Activities to Rebecca Ostertag, Professional Staff Award to Kolby Santiago, Outstanding University Support Employee Award to Kirk Mikami and the Koichi and Taniyo Taniguchi Award for Excellence in Innovation to Keiki Kawaiaea.
Ostertag is an associate professor of biology and the recipient of the Award for Excellence in Scholarly/Creative Activities. She is a highly productive research scientist with a prolific and consistent publication record.
Ostertag emphasizes the "art†of doing science in her teaching, including how to read the primary literature, develop independent research hypotheses, collect and analyze data, and present the findings.
She shares her love for science through her mentoring and continuously receives high teaching evaluations for her hands-on approach and encouraging style.
Santiago is a financial aid counselor in the student affairs office and the recipient of the Professional Staff Award. She counsels and provides information and support for students and parents on financial aid.
While the number of applications has increased dramatically since she started 10 years ago, she has never complained about having double the workload. Santiago is dedicated to her job and works hard to help students receive much needed financial assistance.
A true team player, Santiago really cares about the students and is well-respected by all those who work with her.
Mikami is an accounting clerk in the business office and the recipient of the Outstanding University Support Employee Award. He has contributed to countless improvements to the existing processes and procedures and is always looking to make operations more efficient.
Mikami always exemplifies excellent customer service to everyone he works with. Whenever a problem arises, he takes the initiative to take ownership of it and follows through to its resolution.
His attitude is that everyone pulling together can make UH Hilo a better place to work and a better place for students to get a true education.
Kawaiaea is an assistant professor at the Ka Haka Ula o Keelikolani College of Hawaiian Language and the recipient of the Koichi and Taniyo Award for Excellence and Innovation.
Kawaiaea has been instrumental in the development of the Na Honua Mauli Ola Hawaiian cultural pathways and the Moenaha culture-based curriculum design and instructional method that impact native learners in culturally healthy and responsive ways.
She is a true role model and continuously demonstrates unwavering determination to fulfill goals of excellent teaching while reviving the Hawaiian language.
Ostertag, Santiago, Mikami and Kawaiaea will be recognized for their achievements along with other UH award recipients at the annual Convocation ceremony 10 a.m. Tuesday, Sept. 27 on the UH Manoa campus. The ceremony is open to the public at no charge, and no reservations are needed. For more information on the awards ceremony, visit http://www.hawaii.edu/about/awards.


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Roof Contractor Mount Dora FL
Roof Contractor In Mount Dora FL
Timothy Parks Roofing & Construction Inc. has been operating in the Orlando area for over 40 years, offering professional roofing services to clients throughout the region. As roof contractors in Mount Dora, we take pride in our incomparable workmanship and superior customer service, which is why we provide free estimates as well as industry-trusted warranties on each of our projects. Our staff is fully licensed and insured so you can rest assured that your project is taken care of by experienced professionals who understand the latest trends in roofing technology. With Timothy Parks Roofing & Construction Inc., you're guaranteed a quality job no matter how complex the project may be.
At TPRCI, we're proud to provide our residential and commercial customers with top-rated roofing services. We back up this statement with a multitude of five-star reviews and accreditation. Our commitment to superior craftsmanship is only possible due to the hardworking professionals that make up our team. Seasoned veterans with years of expertise pour their life's work into perfecting the roofing craft, giving us the upper edge that sets us apart from competitors. For projects that require quality work without compromises, you can trust TPRCI as your choice roofing contractor — let our crew turn your dream project into a reality.
Roof Contractor Near Me
For those moments when a roof repair emergency threatens to ruin your day, there's no need to worry - just call one of Timothy Parks Roofing & Construction's expert representatives. Whether you have a leak, storm damage, or need shingle replacement, our team will assess the issue and handle it swiftly so that you can get back to focusing on more important matters. Our same-day service is ideal for both residential and commercial properties. That's why we're the number one choice in roof repairs - experienced, reliable, and with unparalleled efficiency.
We truly believe that a roof should not just be meant to last long but it should have exceptional customer service associated with it. We provide the highest quality of services that help your roof look good and protect your home from storm damage. Our inspection and repair process includes preparation, repair, and added protection. Additionally, our services are affordable and entirely code-compliant to maintain the safety of your family in the home. Our team consists of highly qualified professionals who take great pride in their work and guarantee you complete satisfaction with every job they undertake. With us, you can surely have peace of mind about the health of your roof! We invite you to take a look at some of our past repairs if you find yourself with a free minute. We're confident that you'll be amazed by the quality of our services.


text: Hamburg, Germany, 21 July 2007 (DPA) - The Dalai Lama called on wealthy nations Friday to show more responsibility to poorer countries amid criticism from China over his visit to Germany. 'We live in one world and we have to pay more attention to how we can narrow the gap between rich and poor,' the spiritual and secular leader of Tibetans told a news conference in Hamburg. 'It is the responsibility of rich nations to do more. Creating charitable foundations, for example,' said the 72-year-old, citing the example of US billionaire philanthropist Bill Gates. The Microsoft chairman has donated large amounts of money to various charitable organizations and scientific research programmes through the Bill and Melinda Gates Foundation, established in 2000. 'The world's problems will increase as long as there is a desire to maximise profits,' said the Dalai Lama, who arrived Thursday on a 10-day visit during he will deliver a series of lectures. Criticizing Western consumerism, he urged people to reflect more on their core values, saying it would 'make us happier.' In addition to his lectures, the Tibetan spiritual leader will deliver the keynote speech at a conference of Buddhist nuns organized by the University of Hamburg. The Dalai Lama, who was awarded the Nobel peace prize in 1989 for his efforts to achieve a non-violent solution to the Tibetan problem, will also take part in a panel discussion on 'Learning peace - the practice of non-violence.' In Beijing, the Chinese Foreign Ministry accused the Dalai Lama of trying to divide Tibet and warned Germany not to give him 'a platform to conduct his separatist activities.' It also demanded that no German government officials be allowed to meet with the Tibetan leader 'in order to maintain the healthy and stable development of Sino-German relations.' 'The Dalai Lama is not simply a religious personality, but a political exile with a long history of involvement in separatist activities,' the statement added. Highlight of the visit, the Dalai Lama's fifth to Hamburg, is a series of lectures he is to deliver at the weekend to some 30,000 Buddhists from around the world at the Hamburg tennis stadium. A charismatic figure and noted public speaker, the Dalai Lama will be talking about 'Compassion in the globalized world' and discuss the 400 Verses of Indian master Aryadeva. |


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Eagleville Kitchen, Gas Grill & Fireplace Store
We are conveniently located in Brentwood & have the largest selection of premium outdoor home products in greater Nashville.
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There's a reason so many Eagleville homeowners visit Embers Store for help with making the most of the great outdoors in their backyard, we're the largest specialty outdoor kitchen, gas grill and fireplace store for Middle Tennessee and all of Nashville. Our Brentwood showroom showcases the leading premium brands for designer outdoor kitchens and exciting outdoor living spaces - our selection is a step up from what you find at big box hardware stores.
You can see premium freestanding & built-in gas grills, outdoor kitchen appliances, integrated kitchen storage options, kitchen islands, outdoor vent hoods & heating solutions, outdoor fireplaces and much more, including designer outdoor furniture, fire pits and fire tables. It's everything you need for your home in Eagleville. Embers Store is also Nashville's top destination for homeowners seeking designer indoor fireplaces, wood stoves & inserts, gas logs & fireplace doors.
We're here to help you make the right decisions & are a great resource during the budget planning process - our team has extensive outdoor design & manufacturer experience. If you need a contractor before starting a major outdoor project, we're happy to recommend qualified local professionals to you - we have great relationships with local providers we've met in our showroom.
If you can't make it into the showroom, call us at 615.309.7738 or contact the showroom online with questions. Embers Store services products we sell and delivers to an area within a 30 mile radius of the store - if you think you're too far, just give us a call!


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UnitedHealth Signs on for Text Alerts
UnitedHealthcare Community Plan of Pennsylvania is offering two new text-messaging services for its Medicaid benefit plan customers.
Txt4health and Text4kids, developed by Voxiva Inc., deliver personalized messages to help people follow recommended preventive care guidelines, as well as well-child visits and developmental milestones, respectively. Medicaid customers overindex into SMS use compared to Medicare or employee-sponsored health plan policyholders, the companies said, citing PwC research.
[Health insurers a good fit for the Internet of Things: Celent]
"Txt4health and Text4kids provide useful health information for people in a convenient, cost-effective way, no matter where they are," said Susan Schick, CEO of UnitedHealthcare of Pennsylvania, in a statement.
Other Voxiva clients on the Txt4Health platform include Amerigroup.
Nathan Golia is senior editor of Insurance & Technology. He joined the publication in 2010 as associate editor and covers all aspects of the nexus between insurance and information technology, including mobility, distribution, core systems, customer interaction, and risk ... View Full Bio


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It's no secret that the Obama administration has struggled from the beginning to find a coherent narrative to support the Afghan war it inherited. Or to craft an even remotely coherent strategy. (Other than how to shift the blame when the whole thing implodes.)
But now that General David Petraeus is assuming command, hearts seem suddenly light. There is a sense – or at least a claim – that new leadership in the field will somehow transform an otherwise bleak and worsening situation. This sense is shared across party lines, and it appears likely that Petraeus will be unanimously confirmed in his new role by the Senate Armed Services Committee.
It seems appropriate, therefore, to reread Gen. Petraeus' seminal work, Field Manual 3-24, to get a sense of how he might undertake this transformation. (FM 3-24 is the counterinsurgency guide for the US military. Along with FM 3-24.2, Tactics In Counterinsurgency, it details what every US soldier, from private to four-star is supposed to know about COIN.)
If Afghanistan is, in fact, a COIN engagement – and we must assume POTUS believes it is, since he has nominated a man perceived to be America's foremost COIN expert to lead it – then he should be using the best available COIN guidelines to assess it. Presumably that would be FM 3-24, so I've taken the liberty of extracting key points to use as metrics. The number and italicized sections below are lifted directly from FM 3-24. The snarky (excuse me, I mean insightful) commentary is mine.
1-4. Long-term success in COIN depends on the people taking charge of their own affairs and consenting to the government's rule.
Er . . . then actually having a functioning 'Host Nation' government is a necessary precondition for success?
1-10. For the reasons just mentioned, maintaining security in an unstable environment requires vast resources, whether host nation, U.S., or multinational.
You mean vast, as in hundreds of thousands of troops, similar numbers of development personnel and the cash to fund it all?
1-30. Protracted conflicts favor insurgents, and no approach makes better use of that asymmetry than the protracted popular war.
Nine years and counting. Might be a good time to ask which team has the deeper bench.
1-113. The primary objective of any COIN operation is to foster development of effective governance by a legitimate government.
Oh. Whoops.
1-116. Six possible indicators of legitimacy that can be used to analyze threats to stability include the following:
- The ability to provide security for the populace (including protection from internal and external threats).
- Selection of leaders at a frequency and in a manner considered just and fair by a substantial majority of the populace.
- A high level of popular participation in or support for political processes.
- A culturally acceptable level of corruption.
- A culturally acceptable level and rate of political, economic, and social development.
- A high level of regime acceptance by major social institutions.
How many points do you get for 'none of the above'?
1-121. Unity of effort must be present at every echelon of a COIN operation.
Ah, man, even the VP, those weenies over at State and the National Security Advisor?
1-131. The cornerstone of any COIN effort is establishing security for the civilian populace.
Right. Remind me how many of those provinces were rated as 'fully secure' in the April 2010 review? As I recall, the exact number was, umm . . . is zero a number?
1-134. Insurgencies are protracted by nature. Thus, COIN operations always demand considerable expenditures of time and resources.
Roger that. Just so long as the pull date is before the next election.
Well, shucks. Color me cynical.
In the wildland fire biz we used a quick and dirty little algorithm called TREAT to decide whether to fight or flee. I think it might apply here, too.
- Time
- Resources
- Experience
- Attitude
- Training
The rule was, if you had any three or more, it was a good decision to stand and fight. Any fewer, and it was time to remove your crews from danger.
Using that for AfPak, I'd give the US about 1.2. Pretty good on attitude, fair on training (for that specific environment), way short of time, resources and experience.
The US cannot commit to the 10 to 20 year time frame (starting today!) that is likely necessary to actually succeed. Nor can it come close to putting the necessary number of troops in the field. (Estimated at over 1.4 million with the classic troop density of 20 counterinsurgents per 1,000 population. Yeah, you can count the locals, but at this point, the ANA and ANP are so bad they would have to be subtracted from the total, not added.) And – key point – in terms of experience, the US has yet to win a classical counterinsurgency fight. (Sorry, Iraq doesn't count. It wasn't true COIN, and the US did not win. For an explanation, see Fourth Generation Warfare in a Fifth Generation Conflict.)
Bottom line? Time to run.
Excuse me. I mean 'strategically redeploy'.
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Transparency Market Research Report Add "Household And Industrial Detergents Market - Global Industry Analysis, Size, Share, Growth, Trends, And Forecast, 2012 - 2018" to its database.
Albany, NY -- (SBWIRE) -- 06/06/2013 -- Detergents are chemical compounds exhibiting cleaning properties in diluted solutions. These are mainly alkylbenzenesulfonates and their compounds. Housing detergents include the complete range of detergents used for everyday household cleaning needs. On the other hand, industrial detergents have a wide variety and uses depending on their formulated type.
Browse Report : http://www.transparencymarketresearch.com/household-industrial-detergents.html
The household and industrial detergent market has huge growth potential based on its variety of applications in household uses and industrial uses. The shift in the lifestyle of people and global modernization are the key features of the drivers for household detergents. The mounting use of the washing and laundry industry are the drivers for household detergents. However, increasing industrialization is responsible for the huge demand for industrial detergents. Industries like chemical, paint, textile, paper and automobile are the major demand drivers for industrial detergents.
Technological advancements and budding industrial uses are escalating the demand chart globally. The introduction of new and improved detergents replaces the existing one making the market highly dynamic. Some policies like government regulations, environmental reforms, and CSRs are some of the restraints to the growth of the market. The coming six years hold the key for the future of the household and industrial detergent market.
Asia-Pacific is the fastest growing market for household and industrial detergents followed by the U.S. and the Middle East. China and India are the leaders in demand as well as supply in Asia-Pacific. The U.S. is among the mature markets for household and industrial detergents and hence concentrates on exports. The increasing industrial growth rate of Asia-Pacific has made it an emerging market. The Middle East is also the upcoming market with increasing industrial growth and rise in demand.
Some of the market players in this industry are Alabu Soaps (United States), Tech-Lube Wholesales (United State), Alchemi J.S. Co. (Egypt), Basic Pharma Life Science Pvt. Ltd. (India), Evergreen CommonHealth (HK) Group Ltd. (China), and Elegant Line Trading 408 CC (South Africa).
This research report analyzes this market depending on its market segments, major geographies, and current market trends. Geographies analyzed under this research report include
North America
Asia Pacific
Rest of the World
This report provides comprehensive analysis of
Market growth drivers
Factors limiting market growth
Current market trends
Market structure
Market projections for upcoming years
This report is a complete study of current trends in the market, industry growth drivers, and restraints. It provides market projections for the coming years. It includes analysis of recent developments in technology, Porter's five force model analysis and detailed profiles of top industry players. The report also includes a review of micro and macro factors essential for the existing market players and new entrants along with detailed value chain analysis.
Browse All Market Research Report : http://www.transparencymarketresearch.com/
New Upcoming Report : http://www.transparencymarketresearch.com/thermoformed-plastics-market.html
Browse Bolg : Business Research Industry


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Yes, it's true. I'm blaming God with it.
As we left for the marriage seminar cruise, I was filled with excitement and apprehension. Hubby and I went with a large group from our church and headed for the Caribbean on Nov. 7th , 2016.
Lord, that ship is going to be filled with abundant food. How will I handle it? If someone tries to pressure me to eat, I think I'll clobber 'em. I'm afraid, what if I go crazy and eat everything? How can I explain that to my ladies weight loss support group at church? They all assured me they would be praying for me. How can I be so afraid of "The Gluttony Ship?" Food everywhere I look, food, food, and more food. Lord, how can I manage all this food? Help! Continue reading Blaming God


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· Size: Adult Weight: 220 gr (0.50 Lb)
* Standard measurement: The tiaras are made in traditional headbands, comfortable to use with standard measures.
· Has a headband
· The feathers used are natural, eco-friendly and non-toxic, can have imperfections and differences between them.
Antique Tiara
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The Antique style tiaras magnify that artistic, antique and elegant touch of your party or event, a unique piece with personality and distinction that preserves the fashion and design of an era that appreciated quality, exclusivity, history and style with feathers, for that special person or to take your costume to the next level.
This tiara is comfortable to wear and easily adjustable at the back by means of a length-modifiable device, without messing up your hairdo.
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If you want us to manufacture your own creation, contact us to discuss and estimate cost.
Each product is meticulously hand crafted one at a time. Each is unique and there may be a slight variation from one item to the next
* Preparation and Delivery Time: 4 to 5 weeks with the U.S.A. International and Express Shipping available.


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We should pause to note the death of Angelo Dundee, the "genial trainer" of 15 world champion boxers, most notably Muhammad Ali.
Dundee, 90, died Wednesday night at his home in Tampa. His son Jimmy tells The Associated Press that Dundee was hospitalized last week for a blood clot. According to theLos Angeles Times, the clot "developed during a flight back to his Florida home after visiting Ali in Louisville, Ky., for the boxer's 70th birthday last month."
As NPR's Tom Goldman tells our Newscast Desk, Dundee was a "savvy cornerman who would motivate fighters who wanted to give up and find unorthodox ways to help."
In 1963, for example, the fighter then known as Cassius Clay was dazed in a fight with Henry Cooper. To give his fighter a chance to recover, Dundee made a small tear in Clay's glove slightly larger and appealed to the referee to let him put a new glove on the boxer. As the Times writes, "none were available, but the incident added valuable seconds to Clay's rest time, allowing him to recover and go on to win on a fifth-round technical knockout."
Dundee was in Ali's corner for such great bouts as "the rumble in the jungle" with George Foreman and the classic battles with Joe Frazier.
And, "while Dundee's name was synonymous with Ali's, he worked with 14 further world champions, including Sugar Ray Leonard, George Foreman and Jimmy Ellis, during a distinguished career," the BBC notes.
ESPN has posted a video report about Dundee here.
Copyright 2020 NPR. To see more, visit https://www.npr.org.


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Judge Puts West Virginia Gay Marriage Suit On Hold
< < Back toA federal judge has put a lawsuit challenging West Virginia's ban on same-sex marriage on hold until a federal appeals court decides a similar Virginia case.
U.S. District Judge Robert C. Chambers entered an order Tuesday that stayed the case filed in West Virginia by three couples last October until the 4th U.S. Circuit Court of Appeals decides a case from Virginia.
Gay rights group Lambda Legal filed the lawsuit contending West Virginia's Defense of Marriage Act unfairly discriminates against same-sex couples and their children.
The Charleston Gazette reports that Chambers wrote that "because of the overlap in the issues present" in both cases, the case in West Virginia should await the outcome.
A three judge panel heard arguments in the Virginia case on May 13 in Richmond.


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Training is a course of working on the exhibitions of an individual or a group after some time. The watchword here is getting to the next level. Subsequently, without knowing the qualities and shortcomings of a group as well as their rivals, training a group for maximized execution in sports is undeniably challenging. Two of the primary errands of a mentor are to examine his group or players and his rivals or expected adversaries. Just with this in examination can the mentor form his training plans for progress and max operation in sports.
UFABET of the mentor's own players should be possible in an exhaustive manner by beginning with deciding your playing style and key 무료스포츠중계for max execution in sports
Decide the mentor's playing style.
By the day's end, the recruited mentor will conclude what sort of playing style he/she will bring into the game. Each mentor is unique and will acquire his/her own playing styles. In their primes, the New Jerseys Devils managed the ice utilizing their impartial zone trap leaned toward by their lead trainer. The Atlanta Braves' assets during the 90s relied upon their strong beginning pitching comprising of any semblance of Tom Glavine, Greg Maddux, Rocky Coppingher and such. The World Cup Winning English Team of 1966 played as the 'wingless miracles'. Each mentor will bring various components of playing style into their games. This style set the stage for building the following group with maximized operation in sports.
There has been banter in regards to whether a mentor ought to embrace his playing style to the players available to him or are accessible to him to browse. This is particularly so at top proficient level where top players of the group order multi-million bucks pay rates. How does the lead trainer deal with this sort of players but accomplish max execution in sports. In best cases, mentors with the durability to carry out his playing style or customs in the group will quite often find success. Simply think David Beckham and Sir Alex Ferguson. The previous is a genius 'play kid' of soccer, while the other a severe drill sergeant. Eventually, the mentor tossed out his most well known resource and the proprietors and the board of the club upheld his choice. Furthermore, they are properly compensated with a couple of more time of Championship achievement. Credit to the people who comprehend that the mentor is the main player of the group.
Decide your key playing positions.
When the playing style of the still up in the air, the following couple of steps in group examination are somewhat consecutive, beginning with deciding the vital situations for the group to accomplishing max operation in sports. Fundamentally this includes affirming the principal position in a group that will drive the progress of the group playing style as set out by the coach.This will contrast from one game to another, and it will likewise be different for various mentors, depending in his/her playing style.
A b-ball group that needs to be predominant in the paint should have serious areas of strength for an and power forward to run the paint. Normally, these two positions will be the critical places of the ball group. A rugby crew proposing to play an open backs game will require a strong scrum-half, deadlock and fullback. During the 1980s at the prime of the Italian defnesive soccer achievement, numerous Italian mentors sent a sweeper as their key position. This position fundamentally guarantee that primary safeguard of the soccer group is covered with an additional player behind them. It is likewise a situation from which the group spring speedy counter-goes after that surprised rivals. It was a truly cautious framework that welcomed a ton of analysis from defenders of free-streaming football. Yet, it was additionally profoundly viable in accomplishing maximized operation in sports.
By focusing in one the vital places of the group in view of playing style executed by the mentor, it becomes more straightforward to dissect the ranges of abilities expected by the various positions and players. When these positions are chosen, the mentor can than put out to list down the qualities expected to play these positions. Afterwhich he should either track down the players with these characteristics or train his players to achieve these traits. It make his errand of training more clarity of mind and viable to develop a group for maximized execution in sports.
Jimmy Tong has been a Physical Educator for a considerable length of time in Singapore, with degree in sports science and actual training from Loughborough University in UK. He has broad instructing experience in soccer, floorball and rugby crews in Singapore Schools.He is presently a games advancement official in Singapore schools as well as a functioning giver of sports preparing articles to further develop sports execution in competitors. He desires to empower individuals' prosperity to drop by moving them with genuine games persuasive and motivational stories.


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I would like to use Jetty as a webserver.
I have edited the configuration file at /etc/default/jetty
and set:
# change to 0 to allow Jetty start
# Listen to connections from this network host
# Use 0.0.0.0 as host to accept all connections.
Now I can reach the Jetty webserver at http://192.168.1.10:8080
but I would like to have Jetty listening on port 80.
I have tried this setting in the same configuration file:
# The network port used by Jetty
and then restart Jetty with sudo service jetty restart
but it doesn't work.
How can I change so that the Jetty webserver is listening on port 80?


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Jennifer Dawn is a Business Coach and founder of Best Planner Ever. She began her entrepreneurial career selling apples off her grandfather's tree because a lemonade stand was so "yesterday". She's a serial entrepreneur who has grown two multi-million dollar businesses, is a successful speaker, and author.
Jennifer serves high-achieving entrepreneurs through private business coaching and hands on workshops. She is a master at setting and achieving goals, problem solving, profitability, and cash flow.


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A generic Power of Attorney form is available at this link General Durable Power of Attorney. This form was prepared by Community Legal Services and we have been given permission to share it with clients who have expressed a need for such a form. Some clients may want to use this form to work with others to handle non-criminal matters impacting their lives. Please note that the MCPD does not take any responsibility for its contents or for any consequences that may result from a client or a client's family member(s) using this form. It is merely provided as a convenience for individuals seeking a power of attorney form.
Show All Answers


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What is the advantage on saving the money for the overlord when you have 9 drones, and not filling your supply first and then getting the overlord?
In my theory, in the first case you get to wait the saving time with 9 drones, and get to wait almost the same time with 10 drones in the second case. Second case should be better, since 10 drones mine faster than 9? So why does everybody go with the first case?
All this is assuming you go 12 pool or something like that, where you will get more drones after the overlord. 6- and 8-pools are obviously different.


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I have a domain, let's call it foobar.com. All of the MX records for foobar.com point to Google's mail servers because I am using Google Apps for your domain to manage it. It's great because everyone gets all the advantages of GMail, but our e-mail addresses aren't @gmail.com.
I also have a server. Primarily, it's a web server, but it also serves other things. One of the things it serves is the web site for foobar.com and also sites for various virtual hosts such as shop.foobar.com and forum.foobar.com. The server is running Ubuntu 8.04, because I like using LTS releases in production.
The thing is, there are various applications running on the server that need the ability to send out emails. Various applications, like the cron jobs, send me e-mails in case of errors. Some of the web applications need to send e-mail to users when they forget their passwords, to confirm new registered users, etc. Lastly, it's nice to be able to send e-mail from the command line using the mail command, or mutt.
How can I setup the mail on the web server to go through the Google apps mail servers? I don't need the web server to receive mail, though that would be cool. I do need it to be able to send mail as any legitimate address @foobar.com. That way the forum application can send mails with [email protected] in the from field, and the ecommerce application will have [email protected] in the from field. Also, by sending the mail through the Google servers, we can avoid a lot of the problems with the e-mails being blocked by various spam filters on the web. Google's SMTP servers are trusted a lot more than mine would be.
I'm pretty good with administering Linux systems, but I am absolutely brain dead when it comes to e-mail. I need step by step directions from beginning to end on how to set this up. I need to know every thing to install, and every single change to the configuration files that is necessary. I have tried following various howtos and guides in the past, but none of them were quite right. Either they didn't work at all, or they offered a configuration that is not what I wanted.
Please help. Thanks.


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BullRun – stock.adobe.com
You enter your place of residence or the place where you want to contact the administration or use the location sensing.
In the second step, you choose which information you really need.
Whether it's our weekly shop, petrol for the car or our wages, we all pay taxes and social insurance contributions. Every euro we pay in tax finances state expenditure, for example on social protection and national security. This section gives you an overview of the most important topics, places to seek advice, and services related to taxes, social insurance contributions and charges.