Stoma-related complications and emergencies.

Stoma creations are common procedures in surgical specialties. They can be created either as a temporary or a permanent measure. Despite advancements in surgical technique and stoma care, complications are common. Patients experiencing stoma-related complications often present to the emergency department. Emergency physicians are not expected to be stoma experts, yet they are often the first point of contact for patients experiencing stoma-related complications. Accordingly, emergency physicians should be familiar with the types of stomas and complications and emergencies associated with them so that they can appropriately address the problems related to stomas. This article will provide a review of emergencies and complications associated with ileostomies, colostomies, and urostomies.

Diagnosis and treatment for ocular tuberculosis among uveitis specialists: the international perspective.

PURPOSE: To assess the approach of international specialists, who primarily practice in tuberculosis-endemic areas, to ocular tuberculosis (TB). METHODS: International experts from India, Brazil, Taiwan, and more than 10 other countries were surveyed using two clinical cases and general questions. RESULTS: A total of 244 experts were sent a survey about the treatment and diagnosis of ocular tuberculosis; 65 responded (27%), of whom 34 were affiliated with practices in India, while 31 primarily practice at international sites outside of India and North America. The data from this survey were compared with the results of a similar survey sent to members of the American Uveitis Society. The survey provided normative data on how physicians evaluate patients with uveitis as well as opinions about ocular TB. Responses varied widely on topics such as tests to include in the workup of undifferentiated uveitis, initial therapy, and duration of treatment. Physicians from developing countries relied more on chest CT scans and tuberculin skin testing (TST) than their counterparts in developed countries. CONCLUSIONS: The approach to diagnosis and management of TB is heterogeneous worldwide. However, there are substantial differences in the clinical approach to uveitis depending on the clinician's location of practice.

Lack of consensus in the diagnosis and treatment for ocular tuberculosis among uveitis specialists.

PURPOSE: To assess the approach of specialists to ocular tuberculosis (TB). METHODS: The American Uveitis Society (AUS) Listserv was surveyed using two clinical cases and general questions. RESULTS: Of 196 members, 87 responded (44.4%), of whom 64 were affiliated with practices in North America, while 23 were outside of North America. The survey provided normative data on how physicians evaluate patients with uveitis as well as opinions about ocular TB. Responses varied widely on such issues as (1) the pretest probability that a patient with granulomatous panuveitis had TB uveitis (range 1-75%) or that a patient with a risk factor for TB had ocular TB (range 0-90%); (2) the optimal duration of anti-TB therapy; and (3) whether therapy should be discontinued after 2 months in nonresponders. CONCLUSIONS: Consensus is lacking among uveitis specialists for the diagnosis or management of ocular TB.

Use of intravitreal rituximab for treatment of vitreoretinal lymphoma.

AIM: Vitreoretinal lymphoma is a diffuse large B cell non-Hodgkin lymphoma. Targeting malignant cells with rituximab is being used increasingly as local chemotherapy, but information on this treatment is scant. We aimed to describe current therapeutic approaches, as well as responses to and complications of, intravitreal rituximab in patients with vitreoretinal lymphoma. METHODS: Clinical data were collected in a standardised manner retrospectively on patients with vitreoretinal lymphoma treated with intravitreal rituximab. RESULTS: 48 eyes (34 patients) with vitreoretinal lymphoma were treated with a median of 3.5 intravitreal injections of rituximab (1 mg/0.1 mL) for new diagnosis (68.8%), progressive disease (29.9%) and maintenance therapy (2.1%). Intravitreal rituximab±methotrexate was the sole treatment in 19 eyes (39.6%). 31 eyes (64.6%) eyes achieved complete remission, after a median of 3 injections; 7 of these eyes developed recurrent disease. 11 eyes (22.9%) achieved partial remission. Although rituximab may have contributed to complications reported in 12 eyes (25.0%), a 2-line loss of Snellen visual acuity occurred in only 2 of those eyes (4.2%). CONCLUSIONS: Approaches in rituximab-based intravitreal chemotherapy vary widely, but our findings suggest that this treatment may be safe and effective in inducing remission in a majority of eyes with vitreoretinal lymphoma.

Does phototherapy enhance skeletal muscle contractile function and postexercise recovery? A systematic review.

CONTEXT: Recently, researchers have shown that phototherapy administered to skeletal muscle immediately before resistance exercise can enhance contractile function, prevent exercise-induced cell damage, and improve postexercise recovery of strength and function. OBJECTIVE: To critically evaluate original research addressing the ability of phototherapeutic devices, such as lasers and light-emitting diodes (LEDs), to enhance skeletal muscle contractile function, reduce exercise-induced muscle fatigue, and facilitate postexercise recovery. DATA SOURCES: We searched the electronic databases PubMed, SPORTDiscus, Web of Science, Scopus, and Rehabilitation & Physical Medicine without date limitations for the following key words: laser therapy, phototherapy, fatigue, exercise, circulation, microcirculation, and photobiomodulation. STUDY SELECTION: Eligible studies had to be original research published in English as full papers, involve human participants, and receive a minimum score of 7 out of 10 on the Physiotherapy Evidence Database (PEDro) scale. DATA EXTRACTION: Data of interest included elapsed time to fatigue, total number of repetitions to fatigue, total work performed, maximal voluntary isometric contraction (strength), electromyographic activity, and postexercise biomarker levels. We recorded the PEDro scores, beam characteristics, and treatment variables and calculated the therapeutic outcomes and effect sizes for the data sets. DATA SYNTHESIS: In total, 12 randomized controlled trials met the inclusion criteria. However, we excluded data from 2 studies, leaving 32 data sets from 10 studies. Twenty-four of the 32 data sets contained differences between active phototherapy and sham (placebo-control) treatment conditions for the various outcome measures. Exposing skeletal muscle to single-diode and multidiode laser or multidiode LED therapy was shown to positively affect physical performance by delaying the onset of fatigue, reducing the fatigue response, improving postexercise recovery, and protecting cells from exercise-induced damage. CONCLUSIONS: Phototherapy administered before resistance exercise consistently has been found to provide ergogenic and prophylactic benefits to skeletal muscle.

Angioedema from instant coffee.

Acute allergic angioedema is an abrupt-onset, unpredictable inflammatory reaction of the skin and mucous membranes. Without treatment, the condition may resolve within hours; however, when swallowing or breathing is affected, emergent medical attention is required. We report an atypical presentation of this condition, with a unique dietary cause. A 50-year-old man with no relevant medical history emergently presented with acute angioedema of the lower lip, without urticaria. The inflammation spread to other facial structures but gradually dissipated after subcutaneous epinephrine was administered. Despite thorough questioning of the patient, the cause of the angioedema was not determined. Five days later, during tapered prednisone therapy, the angioedema recurred, and the patient acted to reverse the attack. Instant coffee was identified as the trigger. Beverages are very rarely reported as primary causes of angioedema. To our knowledge, this is the first report of an adult with angioedema triggered not by the caffeine in coffee, but by another characteristic of it.

Blood flow restriction enhances post-resistance exercise angiogenic gene expression.

PURPOSE: The objective of this study is to evaluate the effects of blood flow restriction (BFR) on muscle oxygenation during low-intensity resistance exercise as well as postexercise expression of molecules related to physiological angiogenesis. METHODS: Using a randomized cross-over design, six apparently healthy young adults (22 ± 1 yr) performed 120 unilateral knee extensions at 40% of 1 repetition maximum with and without BFR (CNTRL). Near-infrared spectroscopy was used to measure oxygenation of the vastus lateralis during exercise. Serum and muscle expression of Post-Resistance vascular endothelial growth factor (VEGF) were determined preexercise, 4 h postexercise, and 24 h postexercise. Transcript (mRNA) expression of VEGF and other angiogenic genes was also determined. RESULTS: BFR increased muscle hemoglobin (Hb) concentrations during exercise (14.4 ± 1.6 vs. 0.9 ± 1.6, P = 0.002), driven largely by an increase in deoxygenated Hb (11.0 ± 2.5 vs. 0.5 ± 1.1, P = 0.030). BFR also increased (P < 0.05) transcript expression of VEGF, VEGF-R2, hypoxia-inducible factor 1 alpha, inducible nitric oxide synthase (NOS), and neuronal NOS. The most dramatic change in response to BFR was an increase in VEGF mRNA at 4 h postexercise (4.1 ± 0.6 vs. 0.6 ± 0.2-fold change, P = 0.028). Compared with control, transcript expression of endothelial NOS, serum VEGF, or muscle protein expression of VEGF was not altered in response to BFR (P > 0.05). CONCLUSION: Acute BFR increases postexercise expression of mRNA related to skeletal muscle angiogenesis, plausibly in response to changes in muscle Hb concentrations.

Limb blood flow after class 4 laser therapy.

CONTEXT: Laser therapy is purported to improve blood flow in soft tissues. Modulating circulation would promote healing by controlling postinjury ischemia, hypoxia, edema, and secondary tissue damage. However, no studies have quantified these responses to laser therapy. OBJECTIVE: To determine a therapeutic dose range for laser therapy for increasing blood flow to the forearm. DESIGN: Crossover study. SETTING: Controlled laboratory setting. PATIENTS OR OTHER PARTICIPANTS: Ten healthy, college-aged men (age = 20.80 ± 2.16 years, height = 177.93 ± 3.38 cm, weight = 73.64 ± 9.10 kg) with no current history of injury to the upper extremity or cardiovascular conditions. INTERVENTION(S): A class 4 laser device was used to treat the biceps brachii muscle. Each grid point was treated for 3 to 4 seconds, for a total of 4 minutes. Each participant received 4 doses of laser therapy: sham, 1 W, 3 W, and 6 W. MAIN OUTCOME MEASURE(S): The dependent variables were changes in blood flow, measured using venous occlusion plethysmography. We used a repeated-measures analysis of variance to analyze changes in blood flow for each dose at 2, 3, and 4 minutes and at 1, 2, 3, 4, and 5 minutes after treatment. The Huynh-Feldt test was conducted to examine differences over time. RESULTS: Compared with baseline, blood flow increased over time with the 3-W treatment (F(3,9) = 3.468, P < .011) at minute 4 of treatment (2.417 ± 0.342 versus 2.794 ± 0.351 mL/min per 100 mL tissue, P = .032), and at 1 minute (2.767 ± 0.358 mL/min per 100 mL tissue, P < .01) and 2 minutes (2.657 ± 0.369 mL/min per 100 mL tissue, P = .022) after treatment. The sham, 1-W, and 6-W treatment doses did not change blood flow from baseline at any time point. CONCLUSIONS: Laser therapy at the 3-W (360-J) dose level was an effective treatment modality to increase blood flow in the soft tissues.

Metabolic cost of daily activities and effect of mobility impairment in older adults.

OBJECTIVES: To compare metabolic equivalent (MET) values of common daily tasks in men and women aged 70 and older with normative criteria and to determine the effect of having mobility impairments. DESIGN: Cross-sectional observational study. SETTING: University-based research clinic. PARTICIPANTS: Forty-five participants aged 70 to 90 (mean 76.3 ± 5.1) volunteered to complete 17 daily activities, each lasting 10 minutes. MEASUREMENTS: Oxygen consumption (VO(2) = mL/kg per minute) was measured through a mask using a portable gas analyzer, and MET values were calculated as measured VO(2) /3.5 mL/kg per minute. Values were compared with normative values and between participants with and without mobility impairments. RESULTS: Measured METs were different from the established normative criteria in 14 of 17 tasks performed. Normative values underestimated walking leisurely (0.87 ± 0.12 METs) walking briskly (0.87 ± 0.12 METs), and making beds (1.07 ± 0.10 METs) but overestimated gardening (1.46 ± 0.12 METs) and climbing stairs (0.73 ± 0.18). Participants with impairments had significantly lower METs while gardening, vacuuming or sweeping, stair climbing, and walking briskly, although when METs were adjusted for performance speed, the metabolic costs were 16% to 27% higher for those with mobility impairments. CONCLUSION: Metabolic costs of daily activities are substantially different from normative values in older adults, and having mobility impairments increases this metabolic cost. These results may have implications for practitioners to appropriately prescribe daily physical activities for healthy and mobility-impaired older adults.