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A Urolithiasis prolapsed bladder usually lls with urine chloromycetin 250 mg cheap treatment zinc deficiency, whereas an everted bladder obviously cannot contain urine purchase 500mg chloromycetin visa symptoms nasal polyps. Both Urolithiasis is the most important urinary tract disease conditions are rare 500mg chloromycetin for sale symptoms west nile virus. Bladder eversion or prolapse may in feed lot and range cattle but is seldom a problem in grossly mimic vaginal and uterine prolapse but can be dairy cattle unless dairy veal and steers are included trusted 250mg chloromycetin symptoms kidney. These diets are a major cause of urolithiasis is a severe complication that often results in chemical in feed lot beef animals. High phosphorous diets or improper calcium- phosphorous balance in a ration, again usually Diagnosis associated with a high concentrate diet. Pastures containing large amounts of silica or or abdominal ultrasonography is imperative to assess oxalate. Both ography may be helpful to evaluate the number, loca- conditions allow squamous metaplasia of mucosa tion, and size of calculi within the urinary tract before creating solid nidus formation, narrowing of the surgery. Hypervitaminosis D perhaps because of increased and this may interfere with future breeding. During the winter, animals are reluctant with saline solutions could be tried for bulls of valuable to drink normal amounts when water is extremely genetic base, but prognosis must be guarded. Early castration of male animals contributes to re- in feed lot cattle, but a paucity of controlled data exist duced diameter of the distal urinary tract and is an regarding treatment of intact males. If endemic problems occur, the veterinarian must investigate all potential causes to rectify the problem as quickly as possible. Signs Obstruction of male cattle occurs most commonly at the distal sigmoid region of the urethra. Renal, ureteral, and cystic calculi also are possible, but urethral obstruc- tion is the most common clinical situation. Providing free access to a Subacute infections limited to the umbilicus may source of nonfrozen water is very important, and add- have purulent material that drains from the umbilical ing NaCl to 4% to 5% of the ration will encourage water vessels or urachus after removal of a scab at the exterior consumption and reduce precipitation or accumulation umbilicus. This is especially helpful during ex- Latent infections of intraabdominal vascular rem- treme cold weather. Affected calves may be several weeks old before signs of fever and depression occur. Depending on the pathology present, Patent Urachus in Calves other signs may include signs of peritonitis, septic arthri- Persistence of a patent urachus in calves is less common tis, or urinary tract infection. The umbilicus may appear than in foals but leads to similar predisposition to septi- normal on inspection, but deep palpation may detect cemia. Clinical signs consist of urine dribbling from the thickened umbilical remnants intraabdominally. Diag- antibiotics systemically and cautery of the urachus with nosis is based on palpation, ultrasound examination, silver nitrate or Lugol s iodine are indicated. Umbilical Infections Umbilical Hernias Etiology Etiology and Signs Umbilical infections, hernias, and fetal vascular infec- Uncomplicated umbilical hernias in calves range from tions are common problems in calves. Omentum and abomasum others, such as small hernias and abscesses, may not may be palpated in the hernia. Those that persist require therapy, as titude of intraabdominal lesions and cellulitis or ab- do larger hernias. Neonatal infec- secondary to infected umbilical remnants; cordlike rem- tions of the umbilical region result in painful swelling nants of umbilical structures may be palpated in these and palpable enlargement of the umbilical vessels. Although ticemia resulting from bacteria ascending the umbilical inheritance denitely is a possibility, heifer calves usu- vessels or urachus is always a threat. Infection through ally are not culled because of this problem unless an this route may cause acute septicemia or chronic septi- extremely large hernia exists. Most bull studs will not cemia with subsequent joint ill, meningitis, uveitis, and accept bull calves with hernias (or bulls that have had so on. In some instances, infection is low grade, and no hernias repaired) for fear of perpetuation of the trait. Delayed problems often involve infected urachal Treatment remnants and bladder dysfunction or recurrent urinary Manual reduction of small hernias followed by snug tap- tract infection. The plethora of pathology possible subsequent to the abdominal wall to close the defect. In healthy, rap- umbilical infection requires that each calf be assessed as idly growing calves postweaning, the tape may need to to its individual problems (Table 10-1). Broad-spectrum antibiotic therapy to counteract probable Arcanobacterium vascular thickening with pyogenes or mixed infection possible fever. Assess adequacy of passive transfer of immunoglobulins palpable umbilical lesions, 2. Surgical resection of umbilicus once calf is stabilized (1-3 days) Calf 2 wk or older with fever 1. Umbilicus may hepatic abscessation or require dissection of multiple adhesions appear normal or thickened; 3. If concerned about possible intraabdominal lesions, ultrasound after resolution of external abscess *Specic therapeutic recommendations must address the pathology present in each patient. Surgical preference lution with repeated manual reduction of small hernias, dictates the exact suture pattern, but our clinic has been but these cases may have resolved spontaneously. In pleased with far-near-near-far suture patterns for large larger hernias, or when physical therapy fails, surgery is hernias. Complicated hernias with intraabdominal adhesions Surgery for uncomplicated hernias is performed un- or infected umbilical remnants are difcult surgical pro- der local anesthesia with the calf sedated with xylazine cedures requiring larger incisions, advanced knowledge (up to 0. Sur- examined for problematic remnants, and the abdominal gical referral should be considered for these patients. This refers to the method developed and promoted by the Dutch veterinarian Toussaint Raven and described fully in his excellent book Cattle Hoof Care and Claw Trimming. Toes are cut to 75 mm or 3 in as measured along the dorsal wall from the point near the coronet where the wall becomes hard (this measurement may be increased 3 mm for each 75 kg over 750 kg, or 18 in for every 150 lb over 1600 lb). The 1 Polyurethane hoof block adhesive, two types of blocks, toe thickness is maintained at 5 mm or 4 in at the tip and a heat gun for drying the hoof surface. These dimensions preserve adequate sole thickness (5 mm) at the toe tip to prevent bruising. The heel of the taller claw is trimmed to balance Basic tools for lame cow therapy include left and the weight bearing between the two digits. Additional job, the sole is dished along the axial border of both digits tools that are in wide use are long-handled hoof nip- from the heel-sole junction to the point where the axial pers and electric angle grinders with carbide-toothed wall and white line are evident. There is a wide variety of restraint de- one third and one half the length of the sole. Practitioners should encourage every client to have eliminate the pain rst and foremost and then to correct a safe and efcient place or device for lameness work the underlying problem if possible.

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Arrhythmias: Atrial and ventricular premature beats are usually caused by catheter manipulation but are insignificant and transient order chloromycetin 500 mg treatment definition math. If it persists purchase chloromycetin with a visa medicine while breastfeeding, over- drive pacing or electrical cardioversion is performed for termination discount 500 mg chloromycetin mastercard symptoms 5dpiui. It occurs mainly in sick infants and responds to medical or electrical cardioversion buy 500mg chloromycetin free shipping medicine measurements. Most common sites of perforations are: atrial appendage and right ventricular outflow tract in small infants. Hemopericardium should be suspected if the patient developed hypoten- sion, enlarged cardiac silhouette, and decreased movement of the silhouette nor- mally generated by contractility. Hypoventilation and Apnea Depressed breathing may result from sedation used to perform cardiac catheteriza- tion. It is customary in many centers to have experienced anesthesiologists to be supervising anesthesia/sedation, airway patency, and effec- tive respiration during cardiac catheterization, particularly if patients or procedure are deemed high risk. Embolism This may be systemic or pulmonary and include: Air embolism: this can be prevented by using appropriate size sheath and fre- quent catheter flushing. Allergy It may be precipitated by local anesthetics, iodinated contrast agents, or latex expo- sure. Treatment includes: Diphenhydramine, H2 blockers, fluid resuscitation, and epinephrine. Complications Related to Intervention This includes balloon or device damages to nearby cardiac structures, heart perfora- tions and embolization. Capture and removal of the device is attempted first, if not successful, surgical intervention is necessary to remove embolized device. Death Death rates have declined steeply over the past two decades reaching less than 0. Interventional Catheterization The role of interventional cardiac catheterization in managing children with heart disease continues to expand and include lesions which were, till recently, amenable only to surgical repair. Improvement in tools available for interventional catheterization such as catheters, stents, and devices and the improvement in imaging techniques during procedures 5 Cardiac Catheterization in Children: Diagnosis and Therapy 75 such as transesophageal echocardiography and intracardiac echocardiography in addition to fluoroscopy are allowing safe and effective therapeutic procedures in children with heart diseases. Balloon Atrial Septostomy (Rashkind Procedure) Catheters with inflatable balloons are used to enlarge atrial communications and allow better shunting across the atrial septum. Once the catheter tip is inside the atrium, the stiff balloon is inflated and the catheter is then yanked back. This will cause the inflated balloon to be pulled through the atrial septum and into the right atrium, thus tearing the atrial septum and enlarging the atrial communication. Indications: lesions requiring better mixing of systemic and pulmonary blood at the atrial level, such as in: Transposition of the great arteries with restrictive atrial septal defect. Larger atrial communication will allow better mixing of blood and higher level of oxy- gen saturation till surgical repair is possible. If Rashkind atrial septostomy did not produce an effective atrial communication, then special catheters with blades embedded within an inflatable balloon can be used. The blades are exposed once the balloon is inflated, thus creating cuts in the atrial septal wall to allow for more effective enlarging of the atrial septal defect. Balloon Valvuloplasty Balloon dilation of stenotic valves is a well established technique to eliminate stenosis. Aortic stenosis may be relieved with balloon valvuloplasty as long as aortic regur- gitation is not significant since this may worsen with balloon valvuloplasty. Pulmonary Valve Stenosis Valvar pulmonary stenosis can respond to balloon dilation if the pulmonary annulus size is normal with no significant additional stenosis below or above the valve since supra and subvalvar stenosis do not respond well to balloon dilation. Dilating a stenotic valve results in rupture of the abnormally fused valve cusps, this will result 76 A. Pulmonary valve stenosis is performed when the pressure gradient across the valve is 50 mmHg or more. However, due to the inherent increase in valve regurgitation after balloon dilation procedure, aortic balloon dila- tion should not be performed if the regurgitation is already moderate or severe, since significant aortic valve regurgitation is poorly tolerated. Indications for balloon dilation of aortic valve stenosis include: Newborn and small infants with critical obstruction regardless of the gradient value. Mitral Stenosis Balloon dilation of mitral stenosis is effective in symptomatic rheumatic mitral valve stenosis, but less effective in congenital stenosis. Stenosis due to outgrowing a graft cannot be enlarged with balloon dilation since they are made from materials that are not dis- tensible to prevent aneurysm formation. On the other hand calcification or other pathological process may cause narrowing of the lumen that can be enlarged with balloon dilation. In such circumstances, dilation has to be conducted with extreme care, since rupture of calcified homografts may occur. Dilation can be performed with balloon catheters with or without stent placement, although stents are pre- ferred in many such cases to prevent recoil and restenosis. Stents are usually used in older children (weight more than 20 kg) as large sheaths are needed to deliver and implant such stents. Balloon angioplasty of coarctation of the aorta is the first choice of treatment in cases of recoarctation after previous surgical or balloon dilation procedure. This provides a very effective mode of therapy with a success rate close to 80 90%. On the other hand balloon angioplasty of native coarctation in infants less 6-months of age has higher incidence of residual or recurrent stenosis and aneurysmal formation at the dilation site. Therefore, surgical repair of coarctation of the aorta is preferred in such cases, unless not feasible due to patient instability, then balloon dilation can be attempted as a palliative procedure till more definitive repair can be performed. Pulmonary Artery Stenosis is amenable to balloon angioplasty, this may be required when: There is significant pressure gradient across branch pulmonary arteries causing increase in right ventricular pressure to systemic or near systemic pressures or increase blood flow across the unaffected branch causing pulmonary artery hypertension in the unaffected lung. Main or branch pulmonary artery stenosis is seen in patients with tetralogy of Fallot with pulmonary atresia or hypoplasia, and peripheral pulmonary stenosis such as seen in patients with Williams or Alagille syndromes. Transcatheter Closure of Congenital Cardiac Defects Transcatheter approach has gained wide acceptance as an alternative to open heart surgery in many congenital cardiac defects because of the accurate results and lim- ited complications. In addition, the less invasive nature of the procedure as com- pared to surgery allows for a shorter hospital stay with reduced costs and a faster recovery period. Secundum Atrial Septal Defect Indications: Only secundum atrial septal defects can be closed using devices in the catheterization laboratory. Sinus venosus and primum atrial septal defects are not amenable to this treatment modality due to lack of circumferential atrial septal wall where the device can stay in place once deployed. Once the device is secure in place, the device is freed from its connection to the catheter. The process is visualized through x-ray and echocardiography to ensure proper deployment and effective results. Imaging during the procedure is through fluoroscopy alone, however, additional imaging through echocardiog- raphy may be used. Patent Ductus Arteriosus Indications: Hemodynamically significant ducts (moderate or large), which often cause symptoms (heart failure, recurrent respiratory infections, and failure to thrive) are usually closed during infancy. Closure of hemodynamically insignifi- cant or small ducts with no symptoms during infancy is controversial, particularly if silent (without a murmur) and accidentally discovered during echocardiography. Amplatzer Duct Occluder device is used in patients with significant shunts that manifests with symptoms with left ventricular volume overload and pulmonary hypertension. Methodology: Coil occlusion: An angiogram is performed in the descending aorta to determine the site, size, and shape of the ductus arteriosus.

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Neovascular Glaucoma The elderly patient who presents with a blind and painful eye and who might also be diabetic should be suspected of having neovascular glau- coma cheap 250 mg chloromycetin visa medicine list. Often buy chloromycetin 250mg with amex symptoms you need glasses, a fairly well-dened sequence of events enables the diagnosis to be inferred from the history purchase chloromycetin 500mg overnight delivery medicine jokes, as in many cases secondary neo- vascular glaucoma arises following a central retinal vein occlusion discount chloromycetin 250 mg line treatment ketoacidosis. Some elderly patients do not seek the intraocular pressure rises, the eye tends to attention at this stage and some degree of spon- become painful and eventually degenerates taneous recovery can seem to occur before the in the absence of treatment, and sometimes onset of secondary glaucoma. The patient might say I can t see so well doctor or Looks Normal they might feel that their spectacles need chang- ing. Sometimes, more When the Fundus Is Normal specic symptoms are given; the vision might be blurred,for example in a patient with cataract,or Often a patient will present with a reduction of objects might appear distorted or straight lines vision in one or both eyes and yet the eyes them- bent if there is disease of the macular region of selves look quite normal. Disease of the macular can also make the parents may have noticed an apparent objects look larger or smaller. Double vision is an difculty in reading or the vision may have been important symptom because it can be the result noticed to be poor at a routine school eye test. Patients quite often com- also normal, but before dilating the pupil to plain of oating black spots. If these move slowly allow fundus examination, it is important to with eye movement, they might be caused by check the pupil reactions and to eliminate the some disturbance of the vitreous gel in the centre possibility of refractive error. If they are accompanied by seeing have been checked and the fundus examined, ashing lights, the possibility of damage to the the presence of a normal fundus narrows the retina needs to be kept in mind. The likely diagnosis oaters are common and in most instances are depends on the age of the patient. Patients quite visual deterioration might require an examina- often notice haloes around lights and, although tion under anaesthesia to exclude the possibil- this is typical of an attack of acute glaucoma, ity of a rare inherited retinal degeneration or haloes are also seen by patients with cataracts. Other children, particu- Like many such symptoms, they are best not larly those in the 9 12-year age group, must rst asked for specically. The question do you ever be suspected of some emotional upset, perhaps see haloes? This can make them reluctant to read the test No one can see too well in the dark,but if a patient type. Sometimes such children discover that has noticed a denite worsening of his or her exercising their own power of accommodation ability to see in dim light, an inherited retinal produces blurring of vision and they might degeneration, such as retinitis pigmentosa, present with accommodation spasm. The condition is treatable if caught perhaps less common in general practice and, before the visual reexes are fully developed, for this reason, are easily missed. In the case of the elderly conrmed by looking for a squint or a refractive patient who complains of visual deterioration in error more marked on the affected side. We one eye, the ophthalmoscope all too commonly must also remember that retrobulbar neuritis reveals age-related macular degeneration, but presents in young people as sudden loss of it is also common to nd that the patient has vision on one side with aching behind the suffered a thrombosis of the central retinal eye and a reduced pupil reaction on the vein or one of its branches. This contrasts with amblyopia tion with a central retinal artery occlusion, of disuse, in which the pupil is normal. Temporal arteritis is another and normal fundi might give the history of a important vascular cause of visual failure in stroke and are found to have a homonymous the elderly. At any age, the Hysteria and malingering are also causes of ingestion of drugs can affect the eyesight, but unexplained visual loss, but these are extremely there are very few proven oculotoxic drugs rare and it is important that the patient is still on the market. One important example is investigated carefully before such a diagnosis chloroquine. Although age-related macular degeneration is normally seen in the over-60s, the same problem may occur in When the Fundus Is Abnormal younger people often with a recognised inherit- ance pattern. A completely different condition Quite a proportion of patients who complain of can also affect the macular region of young loss of vision with eyes that look normal on adults, known as central serous retinopathy. The three important potentially blind- few weeks, although treatment by laser coag- ing but eminently treatable ophthalmological ulation is occasionally needed. Unilateral pro- conditions must be borne in mind: cataract, gressive visual loss in young people can also chronic glaucoma and retinal detachment. It is be caused by posterior uveitis,which is the same an unfortunate fact that the commonest cause of as choroiditis. The known causes and manage- visual loss in the elderly is usually untreatable ment of this condition will be discussed in at the present time. Fundus normal Fundus abnormal Child Refractive error Cataract Disuse amblyopia Macular degeneration Inherited retinal degeneration Posterior uveitis Emotional stress Young adult Refractive error Diabetic retinopathy Retrobulbar neuritis Retinal detachment Intracranial space-occupying lesion Macular disease Drug toxicity Hypertension Posterior uveitis Elderly Homonymous haemianopia Macular degeneration Central vein thrombosis Chronic glaucoma Cataract Vitreous haemorrhage Temporal arteritis applied steroids also play a sight-saving role in Treatable Causes of the management of temporal arteritis in the Failing Vision elderly and in the treatment of uveitis. In recent years, the treatment of diabetic retinopathy has Nobody can deny that the practice of ophthal- been greatly advanced by the combined effect mology is highly effective. Many eye diseases of laser coagulation and scrupulous control of can be cured or arrested, and it is possible to diabetes. In the past, about one-half of patients restore the sight fully from total blindness. Retinal detachment is less common than cataract but it provides a situation where the sight could be lost completely and then be fully restored. For the best results, surgery must be carried out as soon as possible, before the retina becomes degenerate, whereas delay before cataract surgery does not usually affect the outcome of the operation. Acute glaucoma is another instance where the sight could be lost but restored by prompt treatment. The treat- ment of chronic glaucoma has less impression on the patient because it is aimed at preventing visual deterioration, although in sight-saving terms it can be equally effective. Before their introduction, many more eyes had to be removed following injury and infection. The proper management of ocular it accounts for loss of reading vision in many trauma often has a great inuence on the visual elderly people. Some myopic patients are sus- result, and the rare but dreaded complication ceptible to degeneration of the retina in later of ocular perforating injuries sympathetic years; known as myopic chorioretinal degener- ophthalmia can now be treated effectively ation, it can account for visual deterioration in with systemic steroids. Amblyopia of disuse has myopes who have otherwise undergone suc- already been mentioned; the treatment is cessful cataract or retinal surgery. One must be careful here before dismissing the patient as untreat- Untreatable Causes of able because on rare occasions a contusion injury to the eye or orbit can result in a haem- Failing Vision orrhage into the sheath of the optic nerve. Some degree of visual recovery can sometimes occur Ophthalmologists are sometimes asked if the in these patients and it has been claimed that sight can be restored to a blind eye and, as a recovery might be helped by surgically opening general rule, one can say that if there is no per- the nerve sheath. There is one odd exception ception of light in the eye, it is unlikely that the to this dramatic form of blindness that can sight can be improved, irrespective of the cause. Patients with retrobulbar neuritis for which there is no known effective treatment (optic neuritis) nearly always recover their and it is sometimes important that the patient vision again, whether or not they receive treat- is made aware of this at an early stage in order ment. The explanation is that the visual loss is to avoid unnecessary anxiety, and perhaps caused by pressure from oedema rather than to unnecessary visits to the doctor. It is ative diseases of the retina fail to respond to hardly necessary to say that any neurological treatment. If the retina is out of place, it can be damage proximal to the optic nerve tends to replaced, but old retinae cannot be replaced produce permanent and untreatable visual with new.

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Prognosis Currently discount 250mg chloromycetin symptoms 8 days before period, there is only limited information available on the survival rate of patients with polymyositis and dermatomyositis order chloromycetin 250 mg on line treatment xerophthalmia. The few studies are mainly based on cohorts from one hospital; they are not population based and they include only a small number of patients order chloromycetin 500 mg line treatment zone tonbridge. With this limitation in mind discount chloromycetin medications ending in pam, the 5-year survival was estimated to be 95% and 10-year survival to be 85 or 89% in two recent papers (28,29). This may be a catabolic effect caused by the systemic chronic inflammation, or it may be a side effect of long-term glucocorticoid treatment, which is a well-known muscle catabolic agent. In patients with myositis, muscle wasting may also be caused by muscle atrophy and damage as a consequence of muscle inflammation, or to nutritional deficits depending on difficulties with swallowing. Because of the inflammatory process and to glucocorticoid treatment, muscle mass may be replaced by fat and muscle wasting may not always be signaled by weight loss. A more appropriate way to follow nutritional status is by assessment of body composition. This can be done by a dual energy X-ray absorptiometry scan, typically used for bone densitometry. Little detailed information on nutritional status is available in the literature that is specific for polymyositis and dermatomyositis. Here, we summarize available infor- mation that we find relevant for patients with myositis after a literature survey. The oxygen is provided to muscle by blood vessels including the small capillaries. By using the macronutrients carbohydrates (glycogen), proteins (amino acids) and fat (fatty acids and glycerol) energy is produced in the mitochondria in muscle cells, and the muscle will be able to contract (30). Glucocorticoids A special problem in patients with myositis that may affect nutritional status is their need for long-term (often over months to years), high-dose, glucocorticoids. Glucocorticoids are used to suppress muscle inflammation by acting on most cell types. The effects on T lymphocytes and macrophages are both direct and indirect, by influencing the mediators released by these cells (31,32). Via this mechanism, blocked gene expression of proinflammatory cytokines will occur and therefore the amount of these inflammatory molecules will decrease. As mentioned previously, it was noticed early that treatment with glucocorticoids had negative effects on muscles and may induce muscle atrophy and also a catabolic state. Glucocorticoids act in several ways to retard growth and promote muscle protein breakdown (35). Some strategies that could possibly be undertaken to counteract these negative effects of glucocorticoids are discussed later. Role of Exercise The catabolic effect of glucocorticoids on muscle tissue is likely to contribute to muscle wasting in patients with myositis who are also affected by catabolism from the muscle inflammation and from physical inactivity as well. In patients who have undergone renal transplant, the negative effect of low or moderate doses (10 12 mg per day) of glucocorticoids on muscles was reversed by physical exercise. There are numerous benefits of exercise in terms of nutritional status in healthy individuals. Although many of these effects have not been evaluated specifically in patients with myositis, they could be assumed to be attributable to these patients. In healthy individuals, the muscle protein metabolism after exercise is negative and food intake is needed in order to gain muscle mass. Because patients with myositis already experience a catabolic state owing to glucocorticoid treatment, the post-exercise meal could be even more important to prevent further muscle protein breakdown. This is best achieved by digesting a combination of carbohydrates and protein after the exercise bout (52). It seems as if early post-exercise ingestion of a nutrient supplement, as opposed to ingestion 2 hours after training, enhances the anabolic effect of whole-body protein (53,54). The fact that patients with myositis are in a catabolic state caused by inflammation and steroid use, this approach, otherwise mostly used by athletes, might be of use in these patients. Dietary Management A diet achieving energy balance with a content of approx 30% fat, 50 to 60% carbohydrates and 10 to 20% protein of total energy is recommended for healthy individuals in Nordic European countries and is likely to be appropriate for patients with myositis as well (52,55). Dietary supplements have become popular and some of these have been tested in clinical trials in patients with various chronic inflammatory diseases. There are a few reports on effects of supplements in patients with polymyositis or dermatomyositis. Gluten Celiac disease or gluten-sensitivity is a chronic intestinal disorder where the upper small intestine is damaged, leading to impaired nutrient uptake in these patients. Anti-gliadin, another antibody associated with celiac disease, has been found with increased frequency in patients with myositis. Thus, celiac disease should be considered in patients with myositis who experience intestinal problems such as diarrhea or weight loss that cannot be explained otherwise. Imple- mentation of a gluten-free diet is important in these cases to avoid malnutrition (59). Supplements In healthy individuals, it is crucial to support the body with adequate nutrients in order to optimize physical exercise and increase muscle mass or muscle endurance. Supplements have become an enormously profitable industry and the effect of most supplements on the market can be questioned. Through basic research, the safety of several different supplements for use in healthy people has been established (60). There is limited information available that is specific to patients with polymyositis and dermatomyositis; information that is available is presented further on in this chapter. A large number of studies have been published on the subject, describing the ergogenic outcome on muscle strength and size when using creatine in combination with resistance training [61 64]. This provides the ability to work out at an enhanced level and results in a greater gain in muscle mass (65). Creatine supplements have recently been evaluated in a placebo-controlled trial in patients with myositis, in combination with stable immunosuppressive treatment and/or steroids (68). The creatine-supplemented group had a significant improvement, compared with the placebo group, in the primary outcome that reflected the ability to undertake high-intensity exercise. Side effects of creatine supplements, for example, muscle cramps and heat intol- erance, have been described. These side effects may be related to an increase in water retention during the initial days of supplementation. Water retention and an increase in muscle mass may cause weight gain while supplementing with creatine (69). The use of creatine supplements with exercise among patients with myositis was without significant side effects and was considered effective and inexpensive (68,70). In animal models with arthritis, it was suggested that creatine supplementation might have an anti-inflammatory action; similar suggestions have been made based on research using cell cultures in which creatine supplementation also had an anti- inflammatory action on endothelial cells.

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