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Aims Musculoskeletal toxicity is a typical side effect of daptomycin (DAP). However, the risk factors have not been well established. Here, we aimed to identify independent factors affecting DAP-induced musculoskeletal toxicity using a combination of machine learning and conventional statistical methods. Methods A population-based, retrospective, observational cohort study was conducted using the Japanese electronic medical record database. Patients who received DAP between October 2011 and December 2020 were enrolled. Two definitions of musculoskeletal toxicity were employed: (1) elevation of creatine phosphokinase (CPK) value more than twice from baseline and >200 IU/L, and (2) >1000 IU/L. First, multiple logistic regression analyses (a conventional statistical method) were performed to identify independent factors affecting CPK elevation. Then, decision tree analyses, a machine learning method, were performed to detect combinations of factors that change CPK elevation risk. Results Of the 2970 patients who received DAP, 706 were included. Elevation of CPK values >200 IU/L and >1000 IU/L occurred in 83 (11.8%) and 17 (2.41%) patients, respectively. In multiple logistic regression analysis, baseline CPK value and concomitant use of hydrophobic statins were commonly extracted as independent factors affecting each CPK elevation, but concomitant use of hydrophilic statins was not. In decision tree analysis, patients who received hydrophobic statins and had high baseline CPK values were classified into the high-risk group. Conclusion Our novel approach revealed new risk factors for CPK elevation. Our findings suggest that high-risk patients require frequent CPK monitoring.

Background. The secondary traumatic brain injury (TBI) consequences are associated with multiple cascades of biochemical reactions caused by initial neurotrauma. We assessed changes in radical oxidation and marker membrane-associated enzymes involved into various redox reactions reflecting basic metabolic processes by measuring creatine phosphokinase (CPK), CPK-BB, adenosine triphosphate (ATP), adenosine diphosphate (ADP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, lactate dehydrogenase (LDH) in the patients with long-term consequences after TBI. Materials and methods. Eighty-two patients (mean age (±SD) 39.04 ± 14.62 years), thirty controls (29.60 ± 4.73 years) were tested for serum CPK, CPK-BB, ATP, ADP measured using spectrophotometry methods according to standard manufacturer’s protocols. Serum AST, ALT, alkaline phosphatase, LDH levels were detected on gas-liquid chromatograph, by calorimetric methods. Results. We found elevated serum CPK level in patients with long-term consequences after TBI compared to controls (P < 0.001, t = 5.073, 95% CI –188.6 to –92.16) with the medians of total CPK of 163.5 ± 14.1 versus 92.6 ± 11.4 pg/ml in the basic and control groups, respectively. We found abnormal high serum CPK-BB level in the basic group with medians of total CPK-BB level of 24.7 ± 2.7 versus 16.14 ± 1.83 IU/L in controls (p < 0.05; t = 4.9). Metabolic changes in our patients were associated with higher LDH content being in direct proportion with disease duration (p < 0.05; r = +0.42); the median of total LDH level was 694.1 ± 16.3 and 381.9 IU/l in basic and control groups (p < 0.05), respectively. The patients investigated were detected with deficiency of macroergic compounds: ATP and ADP being in direct proportion with disease duration over 15 years (p < 0.05; r = +0.67); the medians of total ATP level were 627.60 ± 12.38 and 735.48 ± 14.57 μmol/l (p < 0.05) in the basic and control groups; for ADP: 256.20 ± ± 14.21 versus 273.88 ± 11.42 (p < 0.05), respectively. Conclusions. Patients with long-term consequences after TBI showed higher serum CPK level associated with increased LDH level reflecting bioenergy dyshomeostasis and severity of secondary brain injuries., Актуальность. Формирование отдаленных последствий закрытой черепно-мозговой травмы (ЗЧМТ) сопровождается каскадом биохимических реакций, которые инициируются первичной нейротравмой. Цель работы. Мы оценивали состояние и изменения радикального окисления и маркерных мембранасоциированных ферментов, которые участвуют в различных окислительно-восстановительных реакциях и отражают основные метаболические процессы организма, путем измерения уровней креатинфосфокиназы (КФК), КФК-ВВ, аденозинтрифосфата (АТФ), аденозиндифосфата (АДФ), аспартатаминотрансферазы (АСТ), аланинаминотрансферазы (АЛТ), щелочной фосфатазы, лактатдегидрогеназы (ЛДГ) у пациентов с отдаленными последствиями ЗЧМТ. Материалы и методы. Восемьдесят два больных (средний возраст (±SD) 39,04 ± 14,62 года), тридцать здоровых пациентов (29,60 ± 4,73 года) были протестированы на уровень КФК, КФК-BB, АТФ, АДФ, которые были определены в сыворотке крови спектрофотометрическим методом в соответствии с прилагаемыми стандартными инструкциями. АЛТ, АСТ, щелочная фосфатаза, ЛДГ были измерены хроматографическим и калориметрическим методами. Результаты. Был выявлен повышенный уровень КФК в сыворотке крови больных с отдаленными последствиями ЗЧМТ по сравнению с контролем (р < 0,001; t = 5,07), средний уровень КФК составлял 163,5 ± ± 14,1 против 92,6 ± 11,4 пг/мл у здоровых людей. Нами был выявлен очень высокий уровень КФК-BB в сыворотке крови в общей группе пациентов, у которых средний уровень КФК-BB составлял 24,7 ± 2,7 против 16,14 ± 1,83 МЕ/л в контрольной группе (р < 0,05; t = 4,9). Метаболические изменения у пациентов заключались в более высоких показателях ЛДГ, которые были прямо пропорциональны увеличению продолжительности посттравматического периода (p < 0,05; r = +0,42); в общей и контрольной группах средний уровень ЛДГ составлял 694,1 ± 16,3 и 381,9 МЕ/л соответственно (р, Актуальність. Формування віддалених наслідків закритої черепно-мозкової травми (ЗЧМТ) супроводжується каскадом біохімічних реакцій, які ініціюються первинною ней-ротравмою. Мета роботи. Ми оцінювали стан і зміни радикального окислення та маркерних мембранасоційованих ферментів, що беруть участь у різних окислювально-відновних реакціях та відображають основні метаболічні процеси організму, шляхом вимірювання рівнів креатинфосфокінази (КФК), КФК-ВВ, аденозинтрифосфату (АТФ), аденозиндифосфату (АДФ), аспартатамінотрансферази (AСT), аланінамінотрансферази (AЛT), лужної фосфатази, лактатдегідрогенази (ЛДГ) у пацієнтів із віддаленими наслідками після ЗЧМТ. Матеріали та методи. Вісімдесят два хворі (середній вік (±SD) 39,04 ± 14,62 року), тридцять здорових осіб (29,60 ± 4,73 року) були протестовані на рівень КФК, KФК-BB, ATФ, AДФ, що були вимірювані у сироватці крові спектрофотометричним методом згідно з доданими стандартними інструкціями. AЛT, AСT, лужна фосфатаза, ЛДГ були вимірювані хроматографічним та калориметричним методами. Результати. Було виявлено підвищений рівень КФК у сироватці крові хворих із віддаленими наслідками після ЗЧМТ порівняно з контролем (р < 0,001; t = 5,07), середній рівень КФК становив 163,5 ± 14,1 проти 92,6 ± 11,4 пг/мл у здорових осiб. Ми виявили дуже високий рівень KФК-BB у сироватці крові у загальній групі пацієнтів, де середній рівень KФК-BB становив 24,7 ± 2,7 проти 16,14 ± 1,83 МО/л у контрольній групі (р < 0,05; t = 4,9). Метаболічні зміни в пацієнтів полягали в більш високих показниках ЛДГ, які були прямо пропорційні збільшенню тривалості посттравматичного періоду (p < 0,05; r = +0,42); у загальній та контрольній групах середній рівень ЛДГ становив 694,1 ± 16,3 та 381,9 МО/л відповідно (р < 0,05). В обстежених хворих було виявлено дефіцит макроергічних сполук, а саме АТФ та АДФ, які знаходились у прямій залежності від тривалості захворювання, особливо понад 15 років (р < 0,05; r = +0,67); у загальній групі пацієнтів середній рівень АТФ становив 627,60 ± 12,38 мкмоль/л порівняно з 735,48 ± 14,57 мкмоль/л у групі контролю(р < 0,05); для AДФ: 256,20 ± 14,21 і 273,88 ± 11,42 (p < 0,05) відповідно. Висновки. У пацієнтів із віддаленими наслідками після ЗЧМТ були виявлені високий рівень загальної активності KФК у сироватці крові та підвищення рівня ЛДГ, що відображає біоенергетичний дисгомеостаз та тяжкість перебігу віддалених наслідків травми мозку.

The article presents the biochemical mechanism of narcotic and toxic effects of ethyl alcohol on the human body, lists the life-threatening complications of chronic abuse of ethyl alcohol with a focus on the compartment syndrome. At the end of the article, a clinical observation is presented, in which the compartment syndrome was masked under the diagnosis of acute cerebrovascular accident for a week, and the patient recovered after three sessions of renal replacement therapy. Attention is drawn to the need for a thorough external examination of patients with alcohol intoxication. All patients admitted to the clinic with acute alcohol intoxication should be screened for rhabdomyolysis., В статье представлен биохимический механизм наркотического и токсического действия этилового алкоголя на организм человека, перечислены жизненно опасные ­осложнения хронического злоупотребления этиловым алко­голем с акцентом на синдром позиционного сдавления. В конце статьи приведено клиническое наблюдение, в котором на протяжении недели синдром позиционного сдавления маскировался под диагноз «острое нарушение мозгового кровообращения» и завершился выздоровлением больной после проведения трех сеансов заместительной почечной терапии. Акцентируется внимание на необходимости тщательного ежедневного внешнего осмотра пациентов с алкогольной интоксикацией. Все пациенты, поступающие в клинику в состоянии острой алкогольной интоксикации, должны быть обследованы на предмет наличия у них рабдомиолиза., У статті описаний біохімічний механізм наркотичної і токсичної дії етилового алкоголю на організм людини, перераховані життєво небезпечні ускладнення хронічного зловживання етиловим алкоголем з акцентом на синдром позиційного стиснення. У кінці статті наведене клінічне спостереження, де упродовж тижня синдром позиційного стиснення маскувався під діагнозом «гостре порушення мозкового кровообігу» і завершився одужанням хворої після проведення трьох сеансів замісної ниркової терапії. Акцентується увага на необхідності ретельного зовнішнього огляду пацієнтів з алкогольною інтоксикацією. Усі пацієнти, які надходять у клініку в стані гострої алкогольної інтоксикації, повинні бути обстежені на предмет наявності в них рабдоміолізу.

Objective: the aim of this study was to evaluate the dynamics of the enzyme creatine phospokinase (CPK) in professional soccer players during the competitive period and to develop criteria and standards for the short and long-term adaptation of the athlete's body to physical exertion. Materials and methods: clinical and laboratory monitoring. During two seasons of the national championship 26 soccer players of high sports qualification (age: 26.7±3.1 years, height: 181.5±5.8 cm, fat content in the body: 9.9±1.7%) were examined. All athletes met the following criteria for inclusion in the study: participation in the pre-season, competition period; measurement of CPK level before the start of the season and at all time points after three games during the season; participation time - at least 75 minutes of the match (75-90 min/match); absence of muscle damage and complaints from the muscular system. Results: a twofold increase in the level of CPK was registered on the day after the match; a uniform decrease in the concentration of the enzyme was detected 60-72 hours after the match with the return of indicators to the pre-game level (p

Background: The value of creatine phosphokinase (CPK) monitoring during isotretinoin therapy is still a matter of debate because of the rarity of muscular and kidney damage in this setting. The aim of the study was to investigate the incidence of CPK elevation during a low starting dose isotretinoin regimen and to discuss the clinical approach to patients with increased CPK. Methods: We reviewed the records of the acne patients from 2015 to 2018 at the University of Ferrara and at the University of Modena and Reggio Emilia. Routine clinical and laboratory follow-up was analyzed. Results: The records of 328 patients were included in the study. Abnormal CPK levels were observed in 5.5% of cases. Revised Leeds acne scores and visual assessment scale (VAS) measurements decreased significantly after isotretinoin therapy. Discussion: The adoption of the low starting dose isotretinoin regimen is associated with low incidence of CPK elevation. The finding of CPK over the conventional value of 5 times above the limit was rarely observed and was never associated with kidney damage. Therefore, it should be interpreted as a relatively benign phenomenon that does not require the interruption of isotretinoin therapy and that should be managed mainly through the reassurance of the patient.

Polymyositis (PM) is an uncommon inflammatory myopathy that affects striated muscles. It causes weakness of the limb girdles, neck, and pharyngeal muscles. We are presenting a case of PM which manifested after intrauterine death (IUD). The patient was referred to our hospital for breathing difficulty, 4 days after delivery of a dead fetus. Initially, she was treated in line of puerperal sepsis and peripartum cardiomyopathy. Patient's cardiopulmonary functions improved but she had persistent high-grade fever. Gross muscle weakness was found on day 5 of admission, involving all four limbs, predominantly in proximal muscles and she had dark colored urine. Laboratory tests revealed myoglobinuria, high serum creatine phosphokinase (CPK) levels, and high lactate dehydrogenase (LDH) levels. Polymyositis diagnosed on the basis of high CPK levels, magnetic resonance imaging (MRI) of cervical spine, electromyography (EMG), and muscle biopsy findings. We question, whether the PM could be pathogenically related to the pregnancy? Literature review of the previously reported cases of PM/dermatomyositis and our case report suggests that pregnancy can trigger the new onset of PM. How to cite this article Borse MP, Sahoo TK, Anand KV, Kumar M, Panda D. Postpartum Polymyositis Following Intrauterine Fetal Death. Indian J Crit Care Med 2020;24(8):731–734.

Background In this study, we investigated the risk factors for daptomycin-associated creatine phosphokinase (CPK) elevation and established a risk score for CPK elevation. Methods Patients who received daptomycin at our hospital were classified into the non-elevated or elevated CPK group based on their peak CPK levels during daptomycin therapy. Univariable and multivariable analyses were performed, and a risk score and prediction model for the incidence probability of CPK elevation were calculated based on logistic regression analysis. Results The non-elevated and elevated CPK groups included 181 and 17 patients, respectively. Logistic regression analysis revealed that concomitant statin use (odds ratio [OR], 4.45 [95% confidence interval {CI}, 1.40–14.47]; risk score 4), concomitant antihistamine use (OR, 5.66 [95% CI, 1.58–20.75]; risk score 4), and trough concentration (Cmin) between 20 and Conclusions These results suggested that concomitant use of statins with antihistamines and Cmin ≥20 µg/mL were risk factors for daptomycin-associated CPK elevation. Our prediction model might aid in reducing the incidence of daptomycin-associated CPK elevation.

Dengue fever is an arbovirus (dengue virus DEN) disease caused by bite of mosquitoes, affecting people worldwide but is frequently seen as pandemic in Latin America and Asian countries. Among children it has been the most frequent reason for hospitalization and mortality. Symptoms range from subclinical disease to severe flu-like illness including myalgias. Dengue commonly presents as myalgia but myositis and/or elevated serum creatine phosphokinase (CPK) is rarely witnessed in dengue fever. Therefore, we present a case of dengue fever presenting as myositis: muscle weakness with raised creatine phosphokinase (CPK).

Background The adverse drug reactions (ADRs) related to clonazepam are mild, and only two cases of myotoxicity induced by clonazepam have been reported, with both patients recovering well. We present a unique case of a serious ADR outcome after taking clonazepam. Case presentation A 24-year-old woman with a long-standing history of polio and a 2-year history of epilepsy developed a serious ADR after repeated exposure to oral clonazepam combined with sodium valproate that manifested as myotoxicity and elevated levels of creatine phosphokinase. The patient is currently bedridden and unable to take care of herself. Conclusion Clinicians should be vigilant of the possibility of myotoxicity induced by clonazepam, especially in specific populations such as polio patients or when clonazepam is used in combination therapies.

Background Paravertebral compartment syndrome occurring without trauma is quite rare. We report a case of compartment syndrome that occurred after spinal exercises. Case presentation A 23-year-old Japanese rower developed severe back pain and was unable to move 1 day after performing exercises for the spinal muscles. Initial evaluation at a nearby hospital revealed hematuria and elevated creatine phosphokinase levels. He was transferred to our hospital, where magnetic resonance imaging revealed no hematoma but confirmed edema in the paravertebral muscles. The compartment pressure measurements were elevated bilaterally. Despite his pain being severe, his creatine phosphokinase levels were expected to peak and decline; his urine output was normal; and surgery was undesirable. Therefore, we opted for conservative management. The next day, the patient’s compartment pressure diminished, and his pain levels decreased to 2/10. After 5 days, he was able to walk without medication. Conclusions We present a rare case of compartment syndrome of the paravertebral muscles with good resolution following conservative management. We hope our case findings will help avoid unnecessary surgery in cases of paravertebral compartment syndrome.

Coronavirus disease 2019 has rapidly enveloped the world in a pandemic after emerging in Wuhan, China, in December 2019. We describe a 49-year-old man presenting with fever, cough, dyspnea, and myalgia diagnosed with coronavirus disease 2019 along with rhabdomyolysis and acute kidney injury. The creatine phosphokinase was elevated to 23,800 U/L before trending down to normal levels. Rapid identification and treatment with aggressive intravenous hydration and correction of electrolyte abnormalities remain key to successful management. In a pandemic, often atypical presentations of this new disease have to be considered as differentials for early diagnosis and treatment of life-threatening conditions.

Background Lung cancer is the second most common cancer in both men and women and the leading cause of cancer death worldwide. The development of novel tyrosine kinase inhibitors (TKIs) represented a paradigm shift in the management of lung cancer and has resulted in markedly prolonged survival. Osimertinib is a TKI that was fast-tracked by the United States Food and Drug Administration in 2015 and subsequently approved for the treatment of metastatic epidermal growth factor receptor T790M mutation-positive non-small cell lung cancer. However, despite the generally favorable outcomes associated with osimertinib, rapid development and deployment of any new drug increases the risk of unforeseen adverse effects. Post-marketing surveillance studies therefore play an important role in further elucidating the risks and benefits of novel anti-neoplastic agents. Material and Methods We describe four patients with non-small cell lung cancer who developed myositis after beginning treatment with osimertinib. In addition, we review the literature on osimertinib-associated myositis. Using PubMed, the following terms were searched and relevant citations assessed: creatine phosphokinase, myositis, osimertinib, rhabdomyolysis, osimertinib, and Tagrisso. Case Presentation Thirty-eight patients were treated with osimertinib in our community clinic. Four with non-small cell lung cancer developed myositis after beginning treatment. The onset of symptoms and/or elevation of creatine phosphokinase occurred between two weeks and eleven months after osimertinib was initiated. Alternative causes for myositis were not identified. In two patients, myositis resolved within one month of withdrawing treatment. Two other patients continued osimertinib treatment with close monitoring. Conclusion Myositis is a serious and potentially underreported adverse effect of osimertinib. Previous studies suggest that osimertinib-associated myositis is rare, occurring in less than 1% of patients. However, myositis occurred in over 10% of patients treated with osimertinib in our clinic population. We suggest regular monitoring for myositis among patients being treated with osimertinib and dose-reduction or cessation of treatment if clinically indicated.

Context: Proximal lower limb weakness presenting acutely with or without preceding fever is a strong mimic of Guillain–Barre syndrome (GBS). Benign acute childhood myositis (BACM) forms an important differential diagnosis in such cases. Aim: To characterize the clinical and laboratory findings of patients with BACM for better understanding of the disease. Settings and Design: This prospective longitudinal study was conducted in a tertiary care hospital of northern India. Materials and Methods: Thirty-two patients presenting in the outpatient or emergency clinic of the hospital with severe myalgia that exacerbated with straight leg raising test and fever from July 2016 to July 2017 were included in the study. Statistical Analysis: All the continuous data were expressed as number and percentage or mean ± standard deviation/median. Non-parametric continuous data between groups were analyzed by Friedman’s test. Results: The mean age of the patients was 14.3 (±8.7) years and they presented after a nonspecific febrile illness in most of the cases (53.1%). The symptoms resolved after a mean of 5.7 (±1.6) days. Myalgia was present in 21 (65%) cases, whereas proximal weakness was the prominent finding in 14 (43%) cases. Electrolyte abnormality (hypokalemia) was present in four (12.5%) cases. In all patients, the muscle enzymes (creatine phosphokinase, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, and lactate dehydrogenase) were elevated at presentation, and electromyography showed myopathic pattern. A significant recovery took place in the next 5–7 days. Conclusion: BACM should be actively looked for in cases of painful acute proximal limb weakness in the adolescents.

The article presents the results of studying cortisol concentration and creatine phosphokinase activity in the blood serum of 40 half-sib Ukrainian black and white dairy cows an hour after planned blood extraction, which was a stress experience. We divided the cows into three groups according to the distribution of cortisol concentration in the animals: I – high, II – average and III – low stress resistance. During the research, the cows from these groups were in their fourth month of lactation after their first calving. They were kept untethered in their summer quarters, natural pastures. The aim of the research was to identify the differences in the quality of colostrum, the vitality of the calves up to the age of 6 months, the vitality of the mother-cows, and also the influence of their different adaptation potentials in cases of abortion and stillborn calves among the cows from different groups. At the dairy complex where the research was conducted, the quality of the cows’ colostrum is not monitored. This is typical for most dairy plants of Ukraine. We found that the classes of A and M immunoglobulins did not depend upon which particular groups the animals belonged to, whereas the content of immunoglobulins of class G is 6.7 g/l higher, and the content of total protein is 8.9 g/l higher in the yield of colostrum of the cows from group 1. The influence of cows’ different levels of resistance to stress experiences on their incidence of abortions and stillborn calves was not determined. Gastroenteritis occurred among calves of cows from group 3 three times more often than with those of group 1. Vitality of calves from cows of groups 1 and 2 was significantly higher. Therefore, technological stress experiences of mother-cows have a negative effect upon the quality of colostrum and upon the vitality of calves. This factor ought to be taken into consideration in the exploitation of animals, especially during pregnancy in order to minimise stress and help individuals with less strong nervous systems. Solving the complex problems of increasing the vitality of calves involves in part guaranteeing their provision with colostrum immunity by compulsory control of the colostrum’ quality using a special aerometer (Colostrometer).

An asymptomatic 4.5 years-old Saudi girl was referred to the pediatric hepatology service with presumed liver disease because of the persistently elevated transaminases which were discovered accidently during routine laboratory workup. Alanine aminotransferase was 128 IU/L and aspartate aminotransferase was 143 IU/L. Subsequent investigations in the hepatology clinic revealed normal hepatic workup. Muscle related work up revealed increased creatine phosphokinase, abnormal electromyography and motor nerve conduction. Muscle biopsy was suggestive of early stage muscular dystrophy, and analyses were compatible with limb-girdle-muscle-disease Type 2C. Further confirmation was reached by molecular genetic testing. This case demonstrates that increased transaminases do not always suggest liver disease, and occult muscle disease should always be taken into account while investigating patients with unexplained persistent hypertransaminasemia.

Typhoid fever is an important health concern across the globe. It is caused by the gram negative bacilli, Salmonella Typhi. The clinical manifestations range from a febrile systemic disease to varied spectrum of serious complications like intestinal perforation, circulatory collapse, meningitis and arthritis. Here, the present authors report one such rare complication; a case of rhabdomyolysis due to Salmonella Typhi. The patient came with chief complaints of fever, loose stools, weakness of limbs and inability to walk. As the case had an unusual presentation of gross motor dysfunction, it was challenging to clinically suspect the condition but laboratory investigations pointed towards the diagnosis of typhoid fever.

BACKGROUND: The intense ischemic pain of acute compartment syndrome can be difficult to discriminate from the pain related to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is often only based on clinical findings and performed at a low threshold. Biomarkers of muscle cell damage might help to identify and monitor patients at risk. In patients with fractures, however, markers of muscle cell damage could be elevated because of other reasons associated with the trauma, which would make interpretation difficult. In a review of all patients who underwent emergency fasciotomy in our health care district we aimed to investigate the decision-making process and specifically the use of biomarkers in patients with and without fractures. METHODS: In the southeast health care region of Sweden 79 patients (60 men) with fractures (median age 26 years) and 42 patients (34 men) without associated fractures (median age 44 years) were treated with emergency fasciotomy of the lower leg between 2007 and 2016. Differences in clinical findings, p-myoglobin and p-creatine phosphokinase as well as pressure measurements were investigated. RESULTS: P-myoglobin was analyzed preoperatively in 20% of all cases and p-creatine phosphokinase in 8%. Preoperative levels of p-myoglobin were lower in patients with fractures (median 1065 μg/L, range 200-3700 μg/L) compared with those without fractures (median 7450 μg/L, range 29-31,000 μg/L), p Funding agencies: Linkoping University; Region Ostergotland; Medical Research Council of Southeast Sweden

Objective The aim of our study was to explore the incidence of cardiac involvement in children with dengue infection admitted in a tertiary care hospital and to evaluate the features of cardiac involvement with the severity of dengue fever. Methods This was a cross-sectional study conducted from September 2014 to August 2016. A total of 130 patients with confirmed dengue NS1 antigen or IgM antibody positivity between the ages of 1 month and 18 years were evaluated. On the third day of admission, blood samples for cardiac markers were collected, and electrocardiograms (ECG) and echocardiograms were performed for each patient. Results Of the 130 dengue patients in the study, 60 (46.2%) were males and 70 (53.8%) were females (male to female ratio, 1:1.16). Cardiac involvement was present in 60 (46.2%) children and was more prominent in children with severe dengue (72.7%), followed by dengue with warning symptoms (53.8%) and dengue fever (28.6%). There was no significant correlation between cardiac involvement and primary/secondary dengue. Both ECG and echocardiography changes were significantly correlated with dengue severity, as opposed to cardiac markers. Conclusions Cardiac involvement was present in children with dengue. Evaluation with ECG, echocardiography, and cardiac markers such as creatine phosphokinase-myocardial band (CPK-MB) are required for the management of cardiac complications in children with dengue. Our study showed an association between cardiac involvement and the severity of dengue. Further studies should be framed, and follow-up of dengue patients with cardiac involvement is necessary for therapeutic management.

Compartment syndrome occurs when the pressure within a defined compartmental space increases past a critical pressure threshold jeopardizing the blood supply. Compartment syndrome can occur in any area of the body with closed compartments. The below-knee leg is the most likely compartment to develop acute compartment syndrome, followed by the forearm, thigh, and arm. Rapid diagnosis and treatment can be life or limb saving. Any delay in evaluating and treating patients with lower extremity compartment syndrome can be devastating for the patient. High suspicion is needed to diagnose the condition. The classic signs of compartment syndrome, the “6 P's,” can be deceiving. Advanced diagnostic techniques like peripheral angiography at the earliest can be lifesaving.

Olanzapine is an atypical antipsychotic drug that is being increasingly used as an intentional overdose. It usually presents with reduced and fluctuating level of consciousness and coma. It may rarely present with muscle toxicity by binding to HT2A receptor in skeletal muscle and increasing its permeability. We report a case of such poisoning which had no obvious symptoms but was brought to emergency due to overdose and was found to have acute muscle toxicity as evidenced by raised creatine phosphokinase (CPK) levels. From this, we also want to emphasize that CPK levels should be checked in all the patient's prescribed olanzapine to look for muscle toxicity.

Non-traumatic exertional rhabdomyolysis (exRML) occurs in individuals with normal muscles when the energy supplied to the muscle is insufficient. Here, we report 11 cases of spinning-induced rhabdomyolysis and review related literature. Spinning is a kind of indoor bicycle sport. The 11 patients who were diagnosed with exRML and admitted to CHA Bundang Medical Center were female and their ages ranged from 15 to 46 years. Two to three days prior to the presentation, the patients had attended a spinning class for the first time. All the patients had been otherwise healthy without any known medical illnesses. They were successfully treated without any complications, except mild non-symptomatic hypocalcemia. However, in the literature, severe complications such as compartment syndrome or acute kidney injury had been reported in relation to exRML including spinning-induced rhabdomyolysis. This spinning exercise needs prior guidelines and specific warnings to prevent exertional rhabdomyolysis.

The relationships between pharmacokinetic (PK)/pharmacodynamic (PD) indices and outcomes were investigated in patients with skin and soft tissue infection (SSTI) who received daptomycin at 4mg/kg/day. Efficacy was evaluated in 55 patients from whom Staphylococcus aureus was isolated, with success rates of 94.5% and 69.1% for clinical and microbiological responses, respectively. The odds ratio for the relationship between the area under the day 1 concentration–time curve (AUC0–24h) to the MIC and the probability of clinical success was 1.03 (95% confidence interval [CI] 0.73–1.45), and that for the relationship for probability of microbiological success was 0.94 (95% CI 0.81–1.09). In 82 patients in the safety analysis, only 1 met the creatine phosphokinase (CPK) elevation criteria, and this patient's minimum concentration (Cmin) of plasma daptomycin was 5.37μg/mL. No significant relationship was found between peak CPK and Cmin (Pearson's correlation coefficient −0.0452). In conclusion, no clear correlation between PK/PD indices and the probability of efficacy or safety events was demonstrated when daptomycin was administered in SSTI patients using the clinically recommended dosage of 4mg/kg/day.

Sleep loss is among the most common yet frequently overlooked problems. This disruptive influence is associated with an adverse lipid profile (LP) and consequently results in an increased risk of cardiovascular disease. Furthermore, it has been well established that athletes are increasingly confronted with sleep problems. The aim of this study was to explore the effect of one night of partial sleep deprivation (PSD) on the cardiovascular profile and LP in young, trained athletes. Ten male Taekwondo athletes were randomized for three sleep conditions in a counterbalanced order: (i) following a baseline sleep night (BN), (ii) following PSD at the beginning of the night (PSDBN), and (iii) following PSD at the end of the night (PSDEN). Basal cardiovascular physiological measures were recorded, and blood samples were taken in the fasted state following each sleep session (i.e., in the morning at 07:00 h). The results showed that myoglobin and creatine phosphokinase increased significantly after PSDEN but not after PSDBN. By contrast, no alteration was observed in the LP and physiological parameters following the two types of PSD. In conclusion, these results show that PSDEN increases cardiac damage biomarkers significantly, even though they do not reach clinical significance. Thus, one night of PSD does not affect the physiological responses and biomarkers of LP in Taekwondo athletes.

Background: Organophosphorus (OP) compounds are commonly used pesticides. In OP poisoning, intermediate syndrome (IMS) manifests between the end of the acute cholinergic crisis and delayed neuropathy. Respiratory paralysis in IMS, if identified early can reduce the need for ventilator support, morbidity, and mortality. Serum creatine phosphokinase (CPK) is elevated in IMS. The objectives of our study were to measure serum CPK level, correlate CPK levels with severity of poisoning and estimate atropine dose used. Materials and Methods: A prospective, observational study was conducted for 1-year. Patients diagnosed with OP poisoning were included. Demographic characteristics, type of poison, time since poisoning, Peradeniya Organophosphorus Poisoning (POP) score, serum pseudocholinesterase, CPK levels, atropine dose, and outcome of treatment were documented. Results: Seventy-five patients were recruited of which 57% and 43% were males and females, respectively, with a mean age of 31.48 ± 11.76 years. The most common OP compound was chlorpyriphos followed by triazophos and methylparathion. The time required to reach hospital was 181.26 ± 89.53 min. About 73.3% and 26.7% of patients had mild and moderate poisoning, respectively, as per POP scale. Pseudocholinesterase level was 364 (205-2168) IU. The amount of atropine used was 190.66 ± 78.83 mg. Serial serum CPK values were 279.72 ± 350.21 IU, 389.78 ± 376.33 IU and 163.13 ± 155.15 IU at admission, 48 h, and 96 h after admission, respectively. A weak positive correlation between serum CPK levels and severity of poisoning ( r = 0.352) was observed. All patients recovered completely within 10.69 ± 5.57 days. Three patients developed IMS, and their serial CPK levels were 1837.33 ± 243.19 IU/L, 1935 ± 97.41 IU/L, and 714.66 ± 394.82 IU/L; and recovered in 17 ± 5.6 days. Conclusion: Increased serum CPK levels at 48 h after poisoning was observed in all the patients, but three patients had more than 1500 IU/L, who manifested with IMS. Early diagnosis of IMS by serial estimation of CPK may help in timely intervention and reduce further life-threatening complications.

Summary Background Necrotizing fasciitis (NF) is a life-threatening soft tissue infection. It is usually caused by Streptococcus pyogenes and other Gram-positive bacteria. Several reports, however, emphasize the importance of Gram-negative rods in this infection. Methods We retrospectively studied all cases of monomicrobial necrotizing fasciitis hospitalized in our center during the years 2002–2012. We compared clinical characteristics and outcomes of patients with Gram-negative versus Gram-positive infection. Results Forty-five cases were reviewed, 19 caused by Gram-negative organisms, 10 of them Escherichia coli , and 26 caused by Gram-positive organisms, 10 of them S. pyogenes . Compared to Gram-positive infections, patients with Gram-negative infections were more likely to have a baseline malignancy (9/19, 47.4%) or to have undergone recent surgery (4/19, 42.3%). The 30-day mortality was higher among Gram-negative infected patients (8/19, 42.1% vs. 8/26, 30.8%). Creatine phosphokinase (CPK) was elevated in a minority of patients with Gram-negative necrotizing fasciitis, and its absolute value was lower than in Gram-positive necrotizing fasciitis. Conclusions In our center, 42% of monomicrobial necrotizing fasciitis cases were found to be caused by Gram-negative organisms, mostly E. coli . These infections usually appeared in immunocompromised or postoperative patients, often presented with normal CPK levels, and were associated with high mortality rates.

Renal histology results are very scarce in dengue-associated rhabdomyolysis patients developing acute kidney injury (AKI). We report a case of dengue fever-induced AKI associated to rhabdomyolysis with a renal biopsy showing acute tubular necrosis (ATN) and renal deposition of myoglobin. A 28-year-old patient who presented dengue fever (DF) complicated by severe AKI and rhabdomyolysis is described. The patient required hemodialysis for three weeks. A renal biopsy revealed ATN with positive staining for myoglobin in the renal tubuli. The patient was discharged with recovered renal function. In conclusion, this case report described a biopsy proven ATN associated to DF-induced rhabdomyolysis, in which renal deposition of myoglobin was demonstrated. We suggest that serum creatine phosphokinase should be monitored in DF patients to allow for an early diagnosis of rhabdomyolysis and the institution of renal protective measures.

Background: Food and Drug Administration–approved daptomycin dosing uses actual body weight, despite limited dosing information for obese patients. Studies report alterations in daptomycin pharmacokinetics and creatine phosphokinase elevations associated with higher weight-based doses required for obese patients. Limited information regarding clinical outcomes with alternative daptomycin dosing strategies in obesity exists. Objective: This study evaluates equivalency of clinical and safety outcomes in obese patients with daptomycin dosed on adjusted body weight versus a historical cohort using actual body weight. Methods: This retrospective, single center study compared equivalency of outcomes with two one-sided tests in patients with body mass index ⩾30 kg/m2 who received daptomycin dosed on actual body weight versus adjusted body weight. The primary outcome was clinical failure. Secondary outcomes included 90-day readmission and 90-day mortality. A combined safety endpoint included creatine phosphokinase elevation, patient-reported myopathy, and rhabdomyolysis. Results: A total of 667 patients were screened for inclusion; 101 patients were analyzed with 50 in the actual body weight cohort and 51 in the adjusted body weight cohort. The two regimens were statistically equivalent for clinical failure (2% actual body weight versus 4% adjusted body weight; p < 0.001 for equivalency). The two regimens were also statistically equivalent for 90-day mortality (6% actual body weight versus 4% adjusted body weight; p = 0.0014 for equivalency). Limitations include single center, retrospective design, and sample size. Daptomycin dosing intensified throughout the study period. Conclusion: The two daptomycin dosing cohorts were statistically equivalent for both clinical failure and 90-day mortality. More data are needed to assess outcomes with higher (⩾8 mg/kg/day) daptomycin doses in this patient population.

This study determined if 6-weeks vitamin D2 supplementation (vitD2, 3800 IU/day) had an influence on muscle function, eccentric exercise-induced muscle damage (EIMD), and delayed onset of muscle soreness (DOMS) in National Association for Stock Car Auto Racing (NASCAR) NASCAR pit crew athletes. Subjects were randomized to vitD2 (n = 13) and placebo (n = 15), and ingested supplements (double-blind) for six weeks. Blood samples were collected and muscle function tests conducted pre- and post-study (leg-back and hand grip dynamometer strength tests, body weight bench press to exhaustion, vertical jump, 30-s Wingate test). Post-study, subjects engaged in 90 min eccentric-based exercise, with blood samples and DOMS ratings obtained immediately after and 1- and 2-days post-exercise. Six weeks vitD2 increased serum 25(OH)D2 456% and decreased 25(OH)D3 21% versus placebo (p < 0.001, p = 0.036, respectively), with no influence on muscle function test scores. The post-study eccentric exercise bout induced EIMD and DOMS, with higher muscle damage biomarkers measured in vitD2 compared to placebo (myoglobin 252%, 122% increase, respectively, p = 0.001; creatine phosphokinase 24 h post-exercise, 169%, 32%, p < 0.001), with no differences for DOMS. In summary, 6-weeks vitD2 (3800 IU/day) significantly increased 25(OH)D2 and decreased 25(OH)D3, had no effect on muscle function tests, and amplified muscle damage markers in NASCAR pit crew athletes following eccentric exercise.

Background: In infants under 3 years of age acquired primary hypothyroidism caused by autoimmune thyroiditis is very rare. Hypothyroidism can manifest with different signs and symptoms and has a wide range of presentations from subclinical hypothyroidism to overt form. We describe a child with acquired autoimmune thyroiditis during a very early period of life and with a severe hypothyroidism presentation. Case presentation: A 22-month-old white male patient with normal neonatal screening presented with a six-month history of asthenia and cutaneous pallor. At general clinical and biochemical exams he showed weight gain, statural growth deceleration, poor movements, sleepy expression, instability while walking, myxoedema, bradycardia, open anterior fontanelle, changes in the face habitus, macrocytic anaemia, ascites, and high CPK, creatinine and cholesterol levels. Acquired autoimmune thyroiditis was the final diagnosis. The thyroxine replacement therapy normalized all the clinical and biochemical abnormalities but at the age of 30 months his mental age showed a delay of 6 months. Conclusions: Our case could give useful learning points: i) although the screening for congenital hypothyroidism is routinely performed, a severe hypothyroidism (for example due to autoimmune thyroiditis) can anyway occur early in life and the clinicians should consider this possibility; ii) hypothyroidism can have a misleading and multi-face clinical presentation; iii) anemia, rhabdomyolysis and high creatinine levels should always include the hypothyroidism in the differential diagnosis; iv) thyroxine replacement therapy is able to revert all the clinical manifestations related to the hypothyroidism; v) evaluating the patient's previous pictures could play an important role in resolving a diagnostic conundrum.

Purpose This analysis determined the incidence of serious rhabdomyolysis events reported during trabectedin treatment since the first phase I clinical trial in April 1996 up to September 2010. Methods Search was done in the Yondelis® Pharmacovigilance and Clinical Trials databases using a list of terms according to the Medical Dictionary for Regulatory Activities (MedDRA, v. 13.1), followed by a medical review of all cases retrieved. Total estimated sample was 10,841 patients: 2,789 from clinical trials; 3,926 from compassionate use programs; and 4,126 treated in the marketplace. Two groups were identified: (1) rhabdomyolysis and (2) clinically relevant creatine phosphokinase (CPK) increases without acute renal failure (ARF). Descriptive analysis included demographic, clinical/laboratory data, and contributing/confounding factors. Potential predictive factors were evaluated by multivariate stepwise logistic regression analysis. Possible changes of pharmacokinetics (PK) in patients with rhabdomyolysis were explored using a population PK model. Results The global incidence of rhabdomyolysis was 0.7 %, and most cases occurred in Cycle 2 of treatment. The incidence of fatal cases was 0.3 %. None of the variables evaluated to detect potential risk factors of rhabdomyolysis were predictive. Additionally, CPK increases (without ARF) were detected in 0.4 % of patients as an incidental finding with good prognosis. Conclusions Rhabdomyolysis is an uncommon event during trabectedin treatment. Multivariate analyses did not show any potential factor that could be predictive or represent a significantly higher risk of developing rhabdomyolysis. Nevertheless, close patient monitoring and adherence to drug administration guidelines may help to limit the incidence of this event.

Amiodarone (Amio), a potent anti-arrhythmic drug, is associated with life-threatening pulmonary toxicity involving fibroses and inflammation. A unique nutrient mixture (NM) consisting of lysine, proline, ascorbic acid, N-acetyl cysteine and green tea extract has previously been shown to exhibit a broad spectrum of pharmacological, therapeutic, cardiovas- cular and chemopreventive properties. The present study was undertaken to determine whether the NM exhibits preventive effects on Amio‑induced cardiac toxicity. Six‑week‑old male BALB/c mice were divided into four groups (A-D) of six animals per group. Mice in groups A and C were fed a regular diet for three weeks, while the diets of the mice in groups B and D were supplemented with 1% NM during that period. After three weeks, the mice in groups C and D received daily Amio injections of 50 mg/kg body weight intraperitoneally for 4 days, whilst those in groups A and B received saline alone. At 24 h after the final dose , mice were sacrificed, blood was withdrawn and serum was collected for clinical chemistry of the heart enzymes creatine phosphokinase (CPK) and aspartate aminotransferase (AST). In addition, livers, kidneys, hearts and lungs were excised and weighed. No significant differences in weight gain were identified among the groups and liver, kidney, heart and lung weights were comparable in all four groups. Administration of Amio to group C resulted in a significant increase in serum CPK levels , whereas in NM-fed group D, the CPK levels were comparable to those in the saline injection groups, A and B. Amio administration also resulted in a significant increase in serum AST levels in group C, but not in the group D animals which exhibited similar levels to those of groups A and B. Therefore, the results indicate that NM has the potential to protect against Amio-induced cardiac toxicity.

The intent of this study was to determine whether nutritional supplements [protein (0.4 g·kg −1 ) vs. carbohydrate (0.4 g·kg −1 ) vs. placebo] would affect muscle recovery differently after eccentric exercise-induced muscle soreness in untrained healthy young men (n = 21) aged 20-28 years. During this double-blind randomized block study design, each subject completed three, 3-day trials (separated by = 2 weeks), identical except for treatment, with each subject serving as his own control. Trials began with a bout of right-leg eccentric exercise (Biodex), followed directly by treatment. At 0 (baseline), 24 and 48 hours, data were collected: creatine phosphokinase from pre-exercise blood samples, subjective muscle soreness questions, and strength tests (power, torque, work). ANOVA indicated that exercise caused mild muscle damage, as evidenced by an overall day effect ( p = 0.0001) for muscle soreness, with the lowest median values (0-10 scale) on day 1 (0.7), increasing ( p = 0.0001) on day 2 (3.2), and remaining elevated on day 3 (3.4). We also noted an overall day effect ( p = 0.0001) for creatine phosphokinase, with the lowest median values on day 1 (136 U·L-1), increasing ( p = 0.0001) on day 2 (235 U·L-1), and remaining elevated on day 3 (189 U·L-1). ANOVA revealed no significant treatment effect on indicators of soreness or damage during recovery. Our results indicated that protein or carbohydrate supplement after exercise that caused mild muscle damage did not facilitate muscle recovery in adequately nourished, healthy young men.

Background : Exercise can initiate a cascade of inflammatory and oxidative stress–related events leading to delayed onset muscle soreness. Polyphenols possess antioxidant and anti-inflammatory properties. Objective : The current study examined the effects of a proprietary polyphenolic blend (PB), containing catechins and theaflavins, on exercise performance and recovery following an eccentric exercise challenge. Design : Male participants (18–35 years of age) received placebo or PB at a low dose (PB-L, 1,000 mg/d) or high dose (PB-H, 2,000 mg/d) for 13 weeks. During the 13th week of supplementation, participants completed an eccentric exercise (40 min downhill treadmill run) followed by a strength assessment (peak torque on isokinetic leg extensions) pre-exercise, and 24, 48, and 96 h post-exercise. Muscle soreness (subjective questionnaire), markers of muscle stress (cortisol and creatine phosphokinase [CK]), and antioxidant capacity (ferric reducing ability of plasma [FRAP]) were also assessed. Results : PB-H attenuated the decrease in peak torque observed in the placebo group from pre-exercise to 48 h ( p= 0.012) and 96 h ( p= 0.003) post-exercise. At 48 h post-exercise, PB-H reduced whole body and hamstring soreness ( p =0.029) versus placebo. Chronic consumption of PB improved serum FRAP ( p =0.039). As expected, serum cortisol and CK increased from pre- to post-exercise in all groups; however, by 96 h, cortisol and CK levels returned to pre-exercise levels following PB supplementation. At 96 h, the change in cortisol from pre- to post-exercise was significantly greater in placebo versus PB-H ( p =0.039). Conclusion : These findings show that chronic consumption of PB improved antioxidant status, reduced markers of muscle stress, and promoted strength recovery post-exercise. Keywords: strength; catechins; theaflavins; cortisol; creatine phosphokinase; antioxidant; delayed onset muscle soreness (Published: 18 December 2015) Citation: Food & Nutrition Research 2015, 59: 30034 - http://dx.doi.org/10.3402/fnr.v59.30034

Background and Aims: Perioperative myocardial ischaemia (PMI) is one of the known complications during off pump coronary artery bypass (OPCAB) surgeries. The length of hospital stay is considerably prolonged in patients with PMI. Myocardial protection is an area which is being widely researched currently to prevent or reduce the incidence of PMI. Over the last decade it has become clear that volatile anaesthetic agents are protective in the setting of PMI and reperfusion. Hence, we planned to study the effect of two different volatile anaesthetics as myocardial protective agents in OPCAB surgery. Methods: A total of 40 patients were enrolled for the study; Group A (sevoflurane, n = 20) and Group B (desflurane, n = 20). All patients had a baseline measurement of Trop-T, creatine phosphokinase-MB (CPKMB) and myocardial performance index (MPI) pre-operatively, which was repeated 4 h after the surgery. Chi-square/Fisher test was used to find the significance of the differences between the two agents. Results: Patients were comparable in demographic, baseline, biochemical and echo criteria. Post-operative CPKMB levels (desflurane - 30.85 ± 2.69 u/L; sevoflurane - 29.05 ± 5.26 u/L, P = 0.7) and number of Trop-T positive patients (Sevoflurane - 9; desflurane - 6, P ≥ 0.05) were comparable. Post-operative MPI indicated decreased left ventricular function in sevoflurane group as compared to desflurane group (P ≤ 0.03). Conclusion: Desflurane exerts better cardioprotective effect than sevoflurane as indicated by better MPI in OPCAB surgeries.

A 3-year-old intact female German shepherd dog weighing 25 kg was evaluated for acute onset of staggering gait and flaccid (dropped) tail following immersion in freeze water. Clinical signs included staggering gait, aggressive behavior, postural pain and flaccid tail. Clinical signs progressed in severity for 2-3 hours following immersion in freeze water. The dog was treated using anti-inflammatory medication along with warm fomentation of the affected portion of the tail and complete rest. Dog uneventfully recovered on day 7 of initiation of treatment and no reoccurrence was observed during one month follow up period. Limber tail syndrome is an uncommonly reported condition in German shepherd dogs that should be considered when sudden staggering gait and dropped tail is observed after immersion in too cold water. Recovery is possible with anti-inflammatory drugs and rest.

Objective: Describe the clinical and laboratory profile, follow-up, and outcome of a series of cases of acute viral myositis. Method: A retrospective analysis of suspected cases under observation in the emergency department was performed, including outpatient follow-up with the recording of respiratory infection and musculoskeletal symptoms, measurement of muscle enzymes, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), transaminases (AST and ALT), blood count, C-reactive protein, and erythrocyte sedimentation rate in the acute phase and during follow-up until normalization. Results: Between 2000 and 2009, 42 suspected cases were identified and 35 (27 boys) were included. The median age was 7 years and the diagnosis was reported in 89% in the first emergency visit. The observed respiratory symptoms were cough (31%), rhinorrhea (23%), and fever (63%), with a mean duration of 4.3 days. Musculoskeletal symptoms were localized pain in the calves (80%), limited ambulation (57%), gait abnormality (40%), and muscle weakness in the lower limbs (71%), with a mean duration of 3.6 days. There was significant increase in CPK enzymes (5507 ± 9180 U/L), LDH (827 ± 598 U/L), and AST (199 ± 245 U/L), with a tendency to leukopenia (4590 ± 1420) leukocytes/mm3. The complete recovery of laboratory parameters was observed in 30 days (median), and laboratory and clinical recurrence was documented in one case after 10 months. Conclusion: Typical symptoms with increased muscle enzymes after diagnosis of influenza and self-limited course of the disease were the clues to the diagnosis. The increase in muscle enzymes indicate transient myotropic activity related to seasonal influenza, which should be considered, regardless of the viral identification, possibly associated with influenza virus or other respiratory viruses. Resumo: Objetivo: Descrever o perfil clínico-laboratorial, acompanhamento e desfecho de uma série de casos de Miosite Aguda Viral. Método: Foi conduzida uma análise retrospectiva de casos suspeitos, em observação em unidade de emergência, e seguimento ambulatorial com o registro de sintomas de infecção respiratória, sintomas músculo-esqueléticos, determinação de enzimas musculares, creatina-fosfoquinase (CPK), desidrogenase lática (DHL), transaminases (AST e ALT), hemograma, proteína C reativa e velocidade de hemossedimentação, na fase aguda e acompanhamento, até a normalização. Resultados: Entre 2000 e 2009, 42 casos suspeitos foram identificados e 35 (27 meninos) foram incluídos. A mediana de idade foi 7 anos e o diagnóstico relatado em 89%, na primeira visita de emergência. Os sintomas respiratórios observados foram: tosse (31%), coriza (23%), e febre (63%) com duração media de 4,3 dias. Os sintomas músculo-esqueléticos foram: dor localizada nas panturrilhas (80%), deambulação limitada (57%), marcha anormal (40%), fraqueza muscular nos membros inferiores (71%), com duração média de 3,6 dias. Observou-se elevação importante das enzimas CPK (5507 ± 9180) U/l, DHL (827 ± 598) U/l e AST (199 ± 245) U/l, e tendência a leucopenia (4590 ± 1420) leucócitos/mm3. A recuperação complete dos parâmetros laboratoriais foi observada em 30 dias (mediana) e a recaída clínica e laboratorial em um caso após 10 meses. Conclusão: Os sintomas típicos com enzimas musculares elevadas após diagnóstico de Influenza e o curso auto-limitado foram os indícios para o diagnóstico. A elevação de enzimas musculares indicam a atividade miotrópica transitória relacionada à influenza sazonal que deve ser considerada, à despeito da identificação viral, possivelmente associada com o vírus Influenza ou outros vírus respiratórios. Keywords: Influenza, Acute myositis, Creatine phosphokinase, Palavras-chave: Influenza, Miosite aguda, Creatina-fosfoquinase

Kaori Yabuno,1,2,* Masafumi Seki,1,* Koji Miyawaki,1,2 Yoshihiro Miwa,2 Kazunori Tomono11Division of Infection Control and Prevention, 2Department of Pharmacy, Osaka University Hospital, Osaka, Japan *These authors contributed equally to this workBackground: The recommended daptomycin dosage is 4 or 6 mg/kg/day for the treatment of complicated skin and soft tissue infections or for Staphylococcus aureus bacteremia, endocarditis, and osteomyelitis. Every other day administration is usually recommended for patients with mild to moderate renal impairment. Higher doses (>6 mg/kg/day) have been explored as a possible alternative. Daptomycin is considered a safe anti-methicillin-resistant S. aureus (MRSA) drug, although renal dysfunction may be worsened. In this paper we report on three patients with chronic renal failure who received a higher dose of daptomycin daily for successful treatment for MRSA bacteremia, MRSA osteomyelitis, and methicillin-resistant S. epidermidis (MRSE) endocarditis.Results: Previous administration of other drugs, including vancomycin, teicoplanin, and linezolid, had failed. In spite of daily treatment with daptomycin instead of the recommended alternate day regimen, adverse effects, such as elevation of creatinine and creatine phosphokinase, did not occur.Conclusion: These experiences suggest that administration of high-dose/short-interval daptomycin can be efficient and safe even in the setting of renal dysfunction, and should be considered for the treatment of severe MRSA/MRSE infections in these patients.Keywords: daptomycin, high-dose, renal failure, methicillin-resistant Staphylococcus aureus, creatine phosphokinase

The concept of minimally invasive lumbar disc surgery comprises reduced muscle injury. The aim of this study was to evaluate creatine phosphokinase (CPK) in serum and the cross-sectional area (CSA) of the multifidus muscle on magnetic resonance imaging as indicators of muscle injury. We present the results of a double-blind randomized trial on patients with lumbar disc herniation, in which tubular discectomy and conventional microdiscectomy were compared. In 216 patients, CPK was measured before surgery and at day 1 after surgery. In 140 patients, the CSA of the multifidus muscle was measured at the affected disc level before surgery and at 1 year after surgery. The ratios (i.e. post surgery/pre surgery) of CPK and CSA were used as outcome measures. The multifidus atrophy was classified into three grades ranging from 0 (normal) to 3 (severe atrophy), and the difference between post and pre surgery was used as an outcome. Patients' low-back pain scores on the visual analogue scale (VAS) were documented before surgery and at various moments during follow-up. Tubular discectomy compared with conventional microdiscectomy resulted in a nonsignificant difference in CPK ratio, although the CSA ratio was significantly lower in tubular discectomy. At 1 year, there was no difference in atrophy grade between both groups nor in the percentage of patients showing an increased atrophy grade (14% tubular vs. 18% conventional). The postoperative low-back pain scores on the VAS improved in both groups, although the 1-year between-group mean difference of improvement was 3.5 mm (95% CI; 1.4-5.7 mm) in favour of conventional microdiscectomy. In conclusion, tubular discectomy compared with conventional microdiscectomy did not result in reduced muscle injury. Postoperative evaluation of CPK and the multifidus muscle showed similar results in both groups, although patients who underwent tubular discectomy reported more low-back pain during the first year after surgery.

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T19:00:06Z No. of bitstreams: 1 S0103-84782009000300033.pdf: 166017 bytes, checksum: 45f2bd5e6ca86be0cd81625fc1d074ed (MD5) Made available in DSpace on 2013-08-22T19:00:06Z (GMT). No. of bitstreams: 1 S0103-84782009000300033.pdf: 166017 bytes, checksum: 45f2bd5e6ca86be0cd81625fc1d074ed (MD5) Previous issue date: 2009-06-01 Made available in DSpace on 2013-09-30T19:57:58Z (GMT). No. of bitstreams: 2 S0103-84782009000300033.pdf: 166017 bytes, checksum: 45f2bd5e6ca86be0cd81625fc1d074ed (MD5) S0103-84782009000300033.pdf.txt: 30593 bytes, checksum: f88d1622e6964ada53995d568c34bdfa (MD5) Previous issue date: 2009-06-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T15:14:59Z No. of bitstreams: 2 S0103-84782009000300033.pdf: 166017 bytes, checksum: 45f2bd5e6ca86be0cd81625fc1d074ed (MD5) S0103-84782009000300033.pdf.txt: 30593 bytes, checksum: f88d1622e6964ada53995d568c34bdfa (MD5) Made available in DSpace on 2014-05-20T15:14:59Z (GMT). No. of bitstreams: 2 S0103-84782009000300033.pdf: 166017 bytes, checksum: 45f2bd5e6ca86be0cd81625fc1d074ed (MD5) S0103-84782009000300033.pdf.txt: 30593 bytes, checksum: f88d1622e6964ada53995d568c34bdfa (MD5) Previous issue date: 2009-06-01 O objetivo neste trabalho foi avaliar o efeito do período de descanso (3, 5, 7 e 9 horas) dos suínos no frigorífico (PDF) e da localização dos suínos na carroceria do caminhão (PBO), quando transportados, no inverno ou verão, sobre alguns parâmetros fisiológicos avaliados em 64 fêmeas, com peso médio de 130kg para abate, durante o manejo pré-abate. Para a análise estatística, foram considerados, no modelo de análise da variância, os efeitos de bloco, PDF, PBO e da interação (bloco x PDF), entre outros. O PDF influenciou, significativamente, as concentrações de lactato no sangue e cortisol na saliva. Suínos que descansaram 5 e 7 horas apresentaram maior concentração de lactato em relação aos animais que descansaram 3 e 9 horas. No transporte, a freqüência cardíaca foi muito maior em relação aos demais locais avaliados. Concluiu-se que o incremento do PDF não promove mudanças na freqüência cardíaca, nas concentrações de glicose e CPK no sangue e cortisol na saliva, mas interfere na concentração de lactato no sangue dos suínos. The aim of the research was to evaluate the effect of pig lairage time (PDF=3, 5, 7 and 9 hours) and evaluate the effect of pig position into the truck (PBO) during transportation to slaughterhouse, in winter or summer conditions, on some physiologic parameters evaluated on 64 heavyweight females with mean liveweight of 130kg during pre-slaughter events. The following effects were considered in the statistical analysis of variance model: block (BL=summer farm or winter farm), PDF, PBO and interaction (Block x PDF), under other factors. The PDF influenced significativelly blood lactate and saliva cortisol levels. Pig submitted to 5 and 7 hours of lairage had higher levels of lactate when compared to pigs submitted to 3 and 9 hours of lairage. During transport the heart rate were higher than in other pre-slaughter events. It is concluded that increasing PDF above 3 hours had no effects on heart frequency, glucose and CPK levels and salivary cortisol levels but affects the blood lactate levels. Empresa Brasileira de Pesquisa Agropecuária Suínos e Aves Universidade Estadual Paulista Faculdade de Ciências Agrárias e Veterinárias Grupo de Estudos e Pesquisas em Etologia e Ecologia Animal Dairy and Swine Research and Development Centre Sadia S.A. TRIEL-HT Indústria de Equipamentos Rodoviários Ltda Universidade Estadual Paulista Faculdade de Ciências Agrárias e Veterinárias Grupo de Estudos e Pesquisas em Etologia e Ecologia Animal

Rhabdomyolysis, a clinical syndrome in which skeletal muscle damage and necrosis, is precipitated by multi-therapy is most frequently described during statin treatment. Rhabdomyolysis is a rare, but serious side-effect that may lead to renal failure and dangerous electrolyte abnormalities in patients. We report a case of rhabdomyolysis after 5 years of atorvastatin therapy in an elderly patient, in multi-treatment for coronary artery disease.

Congenital muscular dystrophies (CMDs) are an extremely heterogenous group of neuromuscular diseases. The article presents the general information on clinical and pathogenetic aspects of CMD diagnosis with emphasis on one of the most common forms of nervous system disturbances — merosin-deficient congenital muscular dystrophy (CMD1A). The authors describe clinical pattern of CMD1A, pathogenesis, epidemiological data, approaches to instrumental, morphological and molecular genetic diagnosis, as well as symptomatic treatment and prenatal diagnosis in detail. As long as there are few genetically confirmed clinical cases of CMD1A described in the publications written in Russian, the authors present their 3-year-long follow-up of a child with genetically confirmed diagnosis of CMD1A (mutations c.2049_2050delAG and c.6993-2A > C of gene LAMA2 [compound heterozygous state]). The article presents a detailed discussion of the described case, comparison with results of recent foreign and Russian observational studies of CMD1A in children. It also contains information on differential diagnosis of CMD1A in the structure of other congenital myodystrophies and optimization of molecular genetic diagnosis.

Background Because neither the incidence and risk factors for rhabdomyolysis in the ICU nor the dynamics of its main complication, i.e., rhabdomyolysis-induced acute kidney injury (AKI) are well known, we retrospectively studied a large population of adult ICU patients (n = 1,769). Methods CK and sMb (serum myoglobin) and uMb (urinary myoglobin) were studied as markers of rhabdomyolysis and AKI (RIFLE criteria). Hemodialysis and mortality were used as outcome variables. Results Prolonged surgery, trauma, and vascular occlusions are associated with increasing CK values. CK correlates with sMb (p The logistic regression showed a positive correlation between CK and the development of AKI, with an OR of 2.21. Univariate logistic regression suggests that elevations of sMb and uMb are associated with the development of AKI, with odds ratios of 7.87 and 1.61 respectively. The ROC curve showed that for all three markers a significant correlation with AKI, for sMb with the greatest area under the curve. The best cutoff values for prediction of AKI were CK > 773 U/l; sMb > 368 μg/l and uMb > 38 μg/l respectively. Conclusions Because it also has extrarenal elimination kinetics, our data suggest that measuring myoglobin in patients at risk for rhabdomyolysis in the ICU may be useful.

Organophosphorus (OP), the commonest agent for poisoning in India due to its easy availability, acts by inhibiting acetylcholinesterase at muscarinic and nicotinic receptors. Erythrocyte cholinesterase (EchE) and plasma cholinesterase (PchE) are reduced in OP poisoning, but their estimation is costly and not regularly performed. There are emerging options for new cheaper biochemical markers in relation to OP poisoning. Serum level of creatine phosphokinase (CPK) is often found to be elevated in OP poisoning. This study was conducted to see if CPK may be used as an alternative of cholinesterase levels in blood to assess the severity of OP poisoning. This was a prospective and observational study. Sixty-three patients of OP poisoning without any prior treatment, presenting within 6 hours, were selected and their clinical severity was categorized according to Peradeniya organophosphorus poisoning (POP) scale. Level of serum CPK, blood EchE and pH were measured following admission, and total dose of atropine (mg) until the final clinical outcome (complete recovery or death) was calculated. Student's t-test and Pearson's correlation coefficient was used for the assessment of statistical significance. According to POP scale, clinical severity was mild (score 0-3) in 17 (27%), moderate (score 4-7) in 32 (50.8%) and severe (score 8-11) in 14 (22.2%) patients. Serum CPK, EchE level, blood pH and total atropine dose strongly correlated with clinical severity. Our study recommends serum CPK as an alternative marker.

Evaluation of hematochemical parameters and renal echography after ESWL treatment with Tripter X1 was done on the first 95 patients treated and for whom we had a longer than 3-month follow-up. Creatinine phosphokinase values showed an increase in 24 patients. 12 patients demonstrated an increase in amylasemia. Echographic checks performed the day after treatment revealed the presence of perirenal lesions in 3 cases. As far as amylasemia is concerned, only 1 patient was treated with aprotinin. One of the patients who developed perirenal hematoma had hypertension; another was following an antiaggregant therapy that was temporarily suspended.

Background Increasing the dosage of daptomycin may be advantageous in severe infection by enhancing bactericidal activity and pharmacodynamics. However, clinical data on using daptomycin at doses above 6 mg/kg in Asian population are limited. Methods A retrospective observational cohort study of all hospitalized adult patients treated with daptomycin (> 6 mg/kg) for at least 72 hours was performed in Taiwan. Results A total of 67 patients (40 males) with a median age of 57 years received a median dose of 7.61 mg/kg (range, 6.03-11.53 mg/kg) of daptomycin for a median duration of 14 days (range, 3–53 days). Forty-one patients (61.2%) were in intensive care units (ICU). Sites of infections included complicated skin and soft tissue infections (n = 16), catheter-related bacteremia (n = 16), endocarditis (n = 11), primary bacteremia (n = 10), osteomyelitis and septic arthritis (n = 9), and miscellaneous (n = 5). The median Pitt bacteremia score among the 54 (80.6%) patients with bacteremia was 4. The most common pathogen was methicillin-resistant Staphylococcus aureus (n = 38). Fifty-nine patients (88.1%) were treated with daptomycin after glycopepetide use. Overall, 52 (77.6%) patients achieved clinical success. The all-cause mortality rate at 28 day was 35.8%. In multivariate analysis, the significant predictors of in-hospital mortality in 54 bacteremic patients were malignancies (P = 0.01) and ICU stay (P = 0.02). Adverse effects of daptomycin were generally well-tolerated, leading to discontinuation in 3 patients. Daptomycin-related creatine phosphokinase (CPK) elevations were observed in 4 patients, and all received doses > 8 mg/kg. Conclusions Treatment with high dose daptomycin as salvage therapy was generally effective and safe in Taiwan. CPK level elevations were more frequent in patients with dose > 8 mg/kg.