Pediatric kidney care experience after the 2023 Turkey/Syria earthquake

BACKGROUND/AIMS

Two earthquakes on February 6th, 2023 destroyed ten cities in Türkiye. We report our experience with pediatric victims during these catastrophes, with a focus on crush syndrome related-acute kidney injury (Crush-AKI) and death.

METHOD

A web-based software was prepared. Patient demographics, time under rubble (TUR), admission laboratory data, dialysis, and kidney and overall outcomes were asked.

RESULTS

903 injured children (median age: 11.62 years) were evaluated. Mean TUR was 13 h (Interquartile range-IQR: 32.5), max 240 h). 31 of 32 patients with a TUR of >120 h survived. The patient who rescued after ten days survived.Two-thirds of the patients were given 50 mEq/L sodium-bicarbonate in 0.45% sodium-chloride solution on admission day. 58% of patients were given intravenous fluid (IVF) at a volume of 2000-3000 mL/m2 body surface area (BSA), 40% of 3000-4000 mL/m2 BSA, and only 2% of >4000 mL/m2 BSA. 425 patients had surgeries, 48 suffered from major bleeding. Amputations were recorded in 96 patients. Eighty-two and 66 patients required ventilator and inotropic support, respectively.Crush-AKI developed in 314 patients (36% of all patients). 189 patients were dialyzed. Age > 15 years, creatine phosphokinase (CK)≥20 950 U/L, TUR≥10 h, and the first-day IVF volume < 3000-4000 mL/m2 BSA were associated with Crush-AKI development. 22 deaths were recorded, 20 of 22 occurred in patients with Crush-AKI and within the first 4 days of admission. All patients admitted after 7 days survived.

CONCLUSIONS

This is the most extensive pediatric kidney disaster data after an earthquake. Serum CK level was significantly associated with Crush-AKI at the levels of >20 950 U/L, but not with death. Adolescent age and initial IVF of less than 3000-4000 mL/m2 BSA were also asscoiated with Crush-AKI. Given that mildly injured victims can survive longer periods in the disaster field, we suggest uninterrupted rescue activity for at least 10 days.

Association between creatine phosphokinase level within normal range and bone mineral density in adolescents

Currently, it is unclear whether creatine phosphokinase (CPK) affects bone mineral density (BMD) in adolescents. We sought to clarify the relationship between CPK and total BMD in adolescents aged 12 to 19 years within normal values by conducting this study. A cross-sectional study was conducted using the 2011 to 2018 National Health and Nutrition Survey data to examine 1188 males (average age, 15.2 years) and 1629 females (average age, 15.4 years). In this study, CPK was the independent variable and total BMD was the outcome variable. In addition to using multivariate linear regression models, subgroup analyses were also conducted in order to examine the relationship between CPK levels and total BMD within normal ranges. Significant positive association was observed between the CPK levels and total BMD in adolescents (model 1: 0.0003 [0.0002, 0.0004], model 2: 0.0004 [0.0003, 0.0005] and model 3: 0.0004 [0.0003, 0.0004]). After adjusting for age, gender, race/ethnicity, body mass index, dietary protein intake, dietary protein intake, dietary fiber intake, poverty to income ratio, physical activities, total cholesterol, total protein, blood urea nitrogen, phosphorus, and serum calcium, CPK levels remained significantly associated with BMD (regression coefficients for quartiles 2 to 4 vs quartile1 were 0.0002, 0.0072, and 0.0154, respectively; P for trend <.001). The association was positive even when stratified by age, gender, and race. Further, adolescents aged 16 to 19 years were more likely to report positive relationships than adolescents aged 12 to 15 years. And the phase relationship between total BMD and CPK was further enhanced in boys. The results of our study show that CPK levels within the normal range are positively associated with total BMD in adolescents aged 12 to 19 years. Additionally, CPK may be a potential biomarker of bone health among adolescents.

The diagnostic utility of creatine kinase-MB versus total creatine phosphokinase ratio in patients with non-ST elevation myocardial infarction from unstable angina

Objective:

The present study seeks to find a way to quickly and correctly differentiate myocardial infarction from unstable angina by measuring the creatine kinase-MB/creatine phosphokinase ratio and comparing in non-ST elevation myocardial infarction patients with unstable angina at different time intervals, to improve the health quality of patients with coronary artery disease.

Methods:

The present study is a retrospective epidemiological analysis of 260 patients with non-ST elevation myocardial infarction and 260 patients with unstable angina, including age, sex, creatine kinase-MB, and creatine phosphokinase biomarkers at two-time intervals, including referral (4–8 h from the onset of pain) as the first interval, and 8 h after the first sampling was extracted as the second interval. Moreover, the delta of the creatine kinase-MB/creatine phosphokinase ratio during two interval times was measured.

Results:

In non-ST elevation myocardial infarction patients in the first and second intervals, creatine kinase-MB/creatine phosphokinase ratio was 32.7 and 33.8% higher than the normal laboratory cutoff (positive), respectively, and in the group of unstable angina patients, this index was positive in 31.9 and 30.4% of patients, respectively. There was no significant difference between the mean creatine kinase-MB to creatine phosphokinase index between the patients with non-ST elevation myocardial infarction and unstable angina (p = 0.507). In the first interval, the sensitivity and specificity of this index in differentiating non-ST elevation myocardial infarction from unstable angina were 51.5 and 57.3% (area under the curve = 0.518), respectively. While in the second interval, the sensitivity and specificity of this index were 17.7 and 87.8% (area under the curve = 0.519), respectively. The creatine kinase-MB/creatine phosphokinase delta in the non-ST elevation myocardial infarction group was significantly higher than in patients with unstable angina during different time intervals (p = 0.01).

Conclusion:

According to our results, creatine kinase-MB/creatine phosphokinase index cannot help differentiate the two groups of non-ST elevation myocardial infarction and unstable angina. However, the findings show that higher levels of creatine kinase-MB enzyme and creatine kinase-MB/creatine phosphokinase delta in the early hours, 4–16 h after the onset of pain in non-ST elevation myocardial infarction patients, can be used to differentiate between non-ST elevation myocardial infarction and unstable angina.

Downer cows: a reanalysis of an old data set

AIMS

To compare the performance of two predictive models for the survival of downer cows.

METHODS

The first model had been developed in 1987 using a dataset containing missing values, while the second, new model was developed on the same dataset but using modern data imputation and analytical methods. Missing data were imputed using multiple imputation by chained equations and a logistic regression model fitted to the imputed data, with survival or not as the outcome variable. The predictive ability of the model built on the imputed data was contrasted with the original prognostic model by testing them both on a second smaller but complete data set, collected contemporaneously with the development of the original model but from a different region of New Zealand. Sensitivity, specificity, accuracy, and cut point for the two models were calculated.

RESULTS

The original 1987 model had a slightly higher accuracy than that of the new one with a sensitivity of 0.85 (95% CI = 0.72-0.94) and a specificity of 0.82 (95% CI = 0.7-0.91), using a cut point for the probability of survival = 0.313.

CONCLUSIONS

The original prognostic formula published by Clark et al. in 1987 performed as well as a modern model built on an imputed data set.

CLINICAL RELEVANCE

The use of a prognostic test based on the Clark model should remain an important part of the clinical examination of downer cows by New Zealand veterinarians.Abbreviations: AUC: Area under the curve; AST: Aspartate transaminase activity; CK: Creatine phosphokinase activity; GAM: Generalised additive model; NSAID: Non-steroidal-anti-inflammatory drugs; PCV: Packed cell volume.

[Serum creatine phosphokinase as a predictor of upper limb amputation in electrical trauma]

OBJECTIVE

To study the relationship between serum creatine phosphokinase and outcomes of injury in victims with electrical burns.

MATERIAL AND METHODS

Among 40 patients with electrical injury, 7 (18%) ones underwent upper limb amputation. There were 37 (92.5%) men and 3 (7.5%) women aged 37 (28; 47) years. We analyzed total serum creatine phosphokinase and MB fraction on the first day in patients with and without amputations.

RESULTS

Total serum creatine phosphokinase exceeded the upper reference value in 11 out of 33 patients without amputation and in all 7 patients with limb amputation (p=0.001). Patients with limb amputation had significantly higher total serum creatine phosphokinase and MB fraction (p<0.001 and p=0.030, respectively). Logistic regression equation showed that high total serum creatine phosphokinase significantly influenced amputation rate (p<0.001), as evidenced by odds ratio (42.7, 95% CI 3.5-514.8). ROC analysis revealed the cut-off value of total serum creatine phosphokinase (950 IU/L). Sensitivity was 100% (63; 100), specificity - 94% (86; 94), positive predictive value - 78% (49; 78), negative predictive value - 100% (92; 100).

CONCLUSION

Total serum creatine phosphokinase depends only on severity of electrical and flame burns. Serum creatine phosphokinase is a predictor of upper limb amputation in patients with electrical injury. Total serum creatine phosphokinase ≥ 950 IU/L is significant for upper limb amputation (in CK-MB fraction within the reference values).

[Creatine phosphokinase enzyme elevation in two third-level hospitals of Córdoba]

Introduction

HyperCKemia is defined as the elevation of creatine phosphokinase (CK) levels greater than 1.5 times the upper limit (CK>285 U/L), being produced by multiple causes, which vary according different populations. The main objective of the study was to know the frequency of hyperCKemia in two hospitals in Córdoba and its main causes.

Methods

Retrospective analytical study in two hospitals in Córdoba, Argentina, where all patients over 18 years of age who presented CK values ​​greater than 285 U/L on at least 2 occasions in a period between 1 and 4 weeks were identified, between the years 2015 and 2017.

Results

254 patients with hyperCKemia were identified, the majority were male (n=181, 71.3%) and their median age was 65 years (interquartile range 25-75%=50-73 years). The main causes of hyperCKemia were ischemic myopathy in 99 (39%) patients and drug-induced myopathies in 45 (17.7%), with statins being the most frequently involved drugs in 31 cases. In only 3.1% of the cases the final diagnosis was not reached. Drug-induced hyperCKemias, when compared to other causes, occurred more frequently in patients with a history of chronic kidney disease (9/45 [20%] vs 18/209 [8.6%], p = 0.025) and in non-smokers (41/45 [91.1%] vs. 157/209 [75.1%], p=0.019).

Main conclusion

254 cases of hyperCKemia were observed, the main causes being of ischemic origin and secondary to drug use, especially statins.

[Creatine phosphokinase as a predictor of acute destructive cholecystitis]

OBJECTIVE

To analyze creatine phosphokinase as a predictor of destructive cholecystitis.

MATERIAL AND METHODS

We analyzed 105 patients with various clinical variants of acute calculous cholecystitis (catarrhal, phlegmonous, gangrenous), and comparable age, gender and comorbidities. The study included patients with gallstone disease and gallbladder inflammation aged 30-7 years who underwent laparoscopic cholecystectomy, open cholecystectomy, cholecystectomy through mini-laparotomy. We excluded patients with gallstone disease complicated by mechanical jaundice aged under 30 years and over 70 years old. Control group consisted of 35 patients with exacerbation of chronic calculous cholecystitis. Creatinine phosphokinase (CPK) was analyzed at admission by standard kinetic colorimetric method in all patients with suspected acute cholecystitis. Statistical analysis of data was carried out using the SPSS Statistics 7.0 software in compliance with the principles of statistical analysis adopted for research in biology and medicine.

RESULTS

CPK level was 257.7±27.9 U/L (p<0.05) in patients with acute calculous cholecystitis that is 3.5 times higher than in the control group. We found an increase of concentration of this enzyme depending on severity of gallbladder wall destruction.

CONCLUSION

Analysis of serum creatine phosphokinase can be included in the algorithm of preoperative examination to study the prospects of this approach for predicting severity of acute cholecystitis.

Relation between Serum Creatine Phosphokinase Levels and Acute Kidney Injury among ST-Segment Elevation Myocardial Infarction Patients

Background: Among patients with rhabdomyolysis, the leakage of intracellular skeletal muscle content such as creatine phosphokinase (CPK) into the bloodstream has been associated with an increased risk of acute kidney injury (AKI). We evaluated the possible relationship between serum CPK levels and AKI occurrence among patients with myocyte injury secondary to ST-elevation myocardial infarction (STEMI). Methods: We retrospectively included 2794 patients with STEMI. Patients were stratified according to peak serum CPK levels into mild (<1000 U/L, n = 1603), moderate (1000–5000 U/L, n = 1111), and severe (>5000 U/L, n = 80) categories. The occurrence of AKI was defined by the KDIGO criteria as an increase in serum creatinine (sCR) ≥0.3 mg/dL within 48 h following PCI. The predictive value of CPK for the risk of AKI occurrence was assessed using multivariate logistic regression models. Results: The overall occurrence of AKI was 10.4%. Incidence of AKI showed a gradual increase between patients with mild, moderate, and severe serum CPK level elevations (7.8% vs. 11% vs. 26% respectively; p < 0.001). In multivariate logistic regression models, both moderate or higher (OR 1.6, 95% CI 1.1–2.2; p = 0.01) and severe (OR 2.8 95% CI 1.4–5.6; p = 0.004) serum CPK level elevations were independently associated with AKI. Conclusions: Among STEMI patients, elevated CPK levels were associated with AKI. This association is presumably independent; however, it remains unclear whether it is due to direct toxic (myoglobin-related) or hemodynamic effects (poor left ventricular function). Further studies are required to reveal the underlying mechanism.

Benign acute childhood myositis: Factors associated with muscle symptoms and resolution

BACKGROUND

Benign acute childhood myositis (BACM) is associated with several viral infections. The aim of this study was to evaluate the progression of myositis symptoms, laboratory findings and oseltamivir treatment in children with influenza- and non-influenza-associated BACM.

METHODS

Patients aged 0-18 years old, admitted to the pediatric emergency department in the seasonal influenza period between 2018 and 2020 were retrospectively analyzed. Patients with acute onset calf tenderness, pain, difficulty in walking and elevated serum creatine phosphokinase were included and were grouped according to influenza rapid test kit results as influenza (A and B) positive, and influenza negative. The time to symptom resolution, laboratory data and the oseltamivir treatment were compared between the groups.

RESULTS

There were 94 patients (67 male, 27 female) with a mean age of 77 ± 22 months. Influenza A was detected in 21, influenza B in 27, and neither were detected in 46 patients. Time to symptom resolution of BACM was shorter in the influenza-positive patients than in influenza-negative patients (2.9 ± 1.4 days and 3.5 ± 1.5 days, respectively, P = 0.027). Oseltamivir did not reduce the symptom resolution time in influenza patients. All children had normal hemoglobin and platelet counts, elevated creatine phosphokinase and 76% of them had leukopenia. Neither clinical recurrence nor metabolic disease were reported.

CONCLUSION

Symptoms of BACM tended to resolve slightly earlier in influenza-positive patients and the duration of symptoms was not affected by oseltamivir treatment.

Donor rhabdomyolysis, acute kidney injury and kidney transplant outcomes

BACKGROUND

Donor rhabdomyolysis may constrain kidney utilization due to anticipated unfavorable graft outcomes-especially in combination with acute kidney injury (AKI). There is a paucity of empiric data to inform organ acceptance decision-making.

METHODS

A single-center retrospective cohort study of adult transplant recipients of deceased-donor kidneys with reported donor creatine phosphokinase (CPK) levels was conducted between 2014 and 2020. Recipients of CPK ≥ 1000 U/L kidneys were propensity matched to CPK < 1000 recipients according to outcome-predictive baseline covariates, except AKI.

RESULTS

A total of 254 kidney transplants were propensity matched into CPK ≥ 1000 (n = 90) vs CPK<1000 (n = 90) groups. Transplant outcomes with high versus low CPK kidneys were similar in terms of delayed graft function (p = 0.64), 1-year estimated glomerular filtration rate <25^th percentile (p = 0.69) and mean (p = 0.58), and time to all-cause graft failure (p = 0.58). There was no interaction between AKI and high CPK for these outcomes. Extreme CPK thresholds as high as >8672 U/L were not associated with overall graft survival in the unmatched sample (p = 0.81).

CONCLUSIONS

In a single center study, donor rhabdomyolysis was not associated with short-term kidney transplant graft outcomes, nor was there an additive effect of AKI. However, studies with greater CPK and AKI severity and longer follow-up are warranted. This article is protected by copyright. All rights reserved.

Identification of Risk Factors for Daptomycin-Associated Creatine Phosphokinase Elevation and Development of a Risk Prediction Model for Incidence Probability

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 <30 µg/mL (OR, 14.48 [95% CI, 2.90-87.13]; risk score 5) and ≥30.0 µg/mL (OR, 24.64 [95% CI, 3.21-204.53]; risk score 5) were risk factors for daptomycin-associated CPK elevation. The predicted incidence probabilities of CPK elevation were <10% (low risk), 10%-<25% (moderate risk), and ≥25% (high risk) with total risk scores of ≤4, 5-6, and ≥8, respectively. The risk prediction model exhibited a good fit (area under the receiver operating characteristic curve, 0.85 [95% CI, .74-.95]).

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.

Pea (Pisum sativum) peel extract attenuates DOX-induced oxidative myocardial injury

The goal of this work aimed to evaluate the protective effects of pea (Pisum sativum) peels extract versus doxorubicin-induced oxidative myocardial injury in male mice. The mice were divided into seven groups (n = 7): (I) control group; (II) P. sativum 250 group; (III) P. sativum 500 group; (IV) DOX (3 times alternately of 2.5 mg/kg/week, i.p. for a continuous two-week period) group; (V) Vit. E 100 + DOX group; (VI) P. sativum 250 + DOX group, and (VII) P. sativum 500 + DOX group). Twenty polyphenolic compounds, mainly flavonoid glycosides such as quercetin, kaempferol apigenin, and phenolics compounds were characterized by LC-MS/MS analysis in the examined extract. DOX administration elevated the activities of serum biomarkers of myocardial dysfunction (ALT, AST, ALP, LDH, troponin, CPK, and CK-MB), lipid profile, and proinflammatory cytokines. Also, it decreased cardiac antioxidants (GSH, SOD, GPX, CAT) and increased myocardial markers of oxidative stress (NO and MDA) and inflammatory marker (MPO). As well as it downregulated and upregulated the Bcl-2 (anti-apoptotic gene) and the Bax (pro-apoptotic gene) expressions, respectively. Pre-treatment of DOX-exposed mice with P. sativum or vitamin E (as a reference protective antioxidant) alleviated the changes dose-dependently via DOX-induced cardiotoxicity. These data show that P. sativum has a cardio-protective impact against DOX-induced cardiomyocyte damage in mice via boosting endogenous antioxidants, decreasing inflammation, and regulating BcL-2 and Bax apoptosis pathway, which might be related to the presence of flavonoid glycosides. P. sativum peels are a by-product that could be suggested for further screening as a possible new candidate for therapeutic use.

Factors affecting creatine phosphokinase elevation during daptomycin therapy using a combination of machine learning and conventional methods

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.

A safety and clinical efficacy analysis of PCSK9 monoclonal antibodies in patients with markedly elevated creatine phosphokinase levels

INTRODUCTION

PCSK9 inhibitors (PCSK9i) are often used in statin-intolerant patients, aiming to reduce low-density lipoprotein cholesterol (LDL-C). Along with the growing experience with their use, there is a lack of evidence regarding the safety, tolerability, and clinical utility of PCSK9i in patients with markedly elevated creatine phosphokinase (CPK) levels.

METHODS

We screened a comprehensive HMO database for patients treated with PCSK9i (Jan 2016-Dec 2019), in whom elevated CPK levels (>1,000 U/L) were documented prior to the initiation of therapy. Treatment plans, adherence, and the levels of CPK and LDL-C were analyzed.

RESULTS

Of the 1,600 patients initiating treatment with PCSK9i, 26 had prior CPK values >1,000 U/L [median (IQR): 3,687 (1,876-8,344) U/L]. All 26 patients were previously treated with statins, which presumably resulted in adverse effects (myalgia in 24, and rhabdomyolysis in 5 patients) therefore mandating their discontinuation. Concomitant secondary factors for CPK elevation were present in 11 patients, and included renal failure, rheumatoid disorders, hypothyroidism, intensive exercise, proteinuria and genetic muscular disease. Of the 26 patients treated with PCSK9i, alirocumab was administered to 12 patients, and evolocumab to 14. Following the initiation of treatment with either drug, 24 patients (92%) demonstrated a reduction in CPK of >50%, and in 12 (46%) CPK levels have returned to normal values. With regard to treatment goals, 17 patients (65%) have achieved an LDL-C level of <70 mg/dL, and 12 (46%) have reached a level of <55 mg/dL. No serious adverse reactions were documented, and only 2 patients discontinued the treatment (not due to muscle symptoms or CPK elevation).

CONCLUSIONS

PCSK9i constitute a safe, tolerable, and effective treatment for hyperlipidemia in patients with markedly elevated CPK. While statin intolerance is a major cause for CPK elevation, concomitant etiologies for increased CPK values were rather common.

Incidence of Cardiac Manifestations in Children with Dengue Fever: A Cross-sectional Study

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.

Relationship Between Statin-associated Muscle Symptoms, Serum Vitamin D and Low-density Lipoprotein Cholesterol - A Cross-sectional Study

INTRODUCTION

Statin-associated muscle symptoms (SAMS) can lead to medication non-adherence among statin users. There is a complex relationship between SAMS, vitamin D and low-density lipoprotein cholesterol (LDL-C). The objective of this study was to evaluate the relationship between vitamin D, LDL-C and occurrence of SAMS.

METHODS

This was a cross-sectional study in patients using statins. Thorough patient histories were taken, a clinical examination was conducted and SAMS were recorded. Levels of vitamin D, creatine phosphokinase (CPK) and LDL-C were measured. These parameters were compared amongst statin users with SAMS and those without SAMS. Levels of vitamin D and LDL-C were converted into percentiles and their relationship with SAMS was evaluated in terms of odds ratio. Receiver operating characteristics (ROC) were drawn, taking vitamin D and LDL-C as predictors of SAMS.

RESULTS

A total of 121 statin users were enrolled in this study. Thirty-eight patients (31.4%) presented with SAMS. Significantly lower levels of serum vitamin D were observed amongst statin users with SAMS compared with those without SAMS (19.8 ± 9.67 ng/mL versus 25.0 ± 14.6 ng/mL; 95% confidence interval -10.4 to -0.07; p=0.04). With vitamin D levels less than or equal to 5th, 10th and 25th percentile, the chances of occurrence of SAMS were significantly higher, but not at the 50th percentile (corresponding vitamin D level of 20.21 ng/mL). LDL-C did not show any conclusive relationship with SAMS. ROC curves showed a significant discrimination for vitamin D levels, but not for LDL-C.

CONCLUSION

Statin users with low levels of vitamin D are at increased risk of developing SAMS. However, LDL-C status of statin users failed to predict any meaningful association with SAMS. Given the small sample size of this study, these results should be regarded as preliminary.

Diagnosis and Management of Rhabdomyolysis in the Absence of Creatine Phosphokinase: A Medical Record Review

INTRODUCTION

Rhabdomyolysis is often encountered in austere environments where the diagnosis can be challenging due to the expense or unavailability of creatine phosphokinase (CPK) testing. CPK concentration ≥5,000 U/L has previously been found to be a sensitive marker for progression to renal failure. This study sought to propose a model utilizing an alternate biomarker to allow for the diagnosis and monitoring of clinically significant rhabdomyolysis in the absence of CPK.

MATERIALS AND METHODS

We performed a retrospective chart review of 77 patients admitted to a tertiary medical center with a primary diagnosis of rhabdomyolysis. A linear regression model with aspartate aminotransferase (AST) as the independent variable was developed and used to predict CPK ≥5,000 U/L on admission and CPK values on subsequent hospital days. The study was approved and monitored by the Institutional Review Board at Walter Reed National Military Medical Center.

RESULTS

Ln(AST) explained over 80% of the variance in ln(CPK) (adjusted R2 = 0.802). The diagnostic accuracy to predict CPK ≥5,000 U/L was high (AUC 0.959; 95% CI: 0.921-0.997, P < 0.001). A cut point of AST ≥110 U/L in our study population had a 97.1% sensitivity and an 85.7% specificity for the detection of a CPK value ≥5,000 U/L. The agreement between actual CPK and predicted CPK for subsequent days of hospitalization was fair with an intraclass correlation coefficient of 0.52 (95% CI: 0.38-0.63). The developed model based on day 1 data tended to overpredict CPK values on subsequent hospital days.

CONCLUSIONS

We propose a threshold concentration of AST that has an excellent sensitivity for detecting CPK concentration ≥5,000 U/L on day of admission in a patient population with a diagnosis of rhabdomyolysis. A formula with a fair ability to predict CPK levels based on AST concentrations on subsequent hospital days was also developed.

Rhabdomyolysis in a Patient With Coronavirus Disease 2019

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.

Tribulus Terrestris may decrease muscle damage markers following a high-intensity resistance exercise: A pilot study

The purpose of this study was to investigate the effect of two weeks of Tribulus Terrestris (TT) on the responses of Interleukin-6 (IL-6), high sensitivity C-reactive protein (hs-CRP), and enzymes creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) following a single session of resistance exercise (RE). Eighteen healthy non-athlete males (age: 22.44 ± 2.54 years, BMI: 26.15 ± 1.62 kg/m²) participated in this study and were divided randomly into two 9-person groups of supplementation or placebo. The participants consumed two 250-mg capsules of TT or placebo (maltodextrin) per day and performed six REs with the intensity 80, 85, and 90% of 1RM in three circles at the day after the end of supplementation period. Blood samples were collected before the initiation of supplementation, and before and after the RE session. Total changes of IL-6 (p<0.001) and LDH (p=0.005) were significant in both groups. Bonferroni post hoc test showed that increased values of IL-6 and CPK in both groups were significant after exercise compared with pre-exercise and baseline (p<0.001). There were no significant differences in relation to within- and between-group changes in hs-CRP (p>0.05). Moreover, differences between the groups regarding post-exercise IL-6 and CPK were not significant (p>0.05). However, post-exercise LDH in supplementation group were lower than placebo group (p=0.015). In conclusion, short-term supplementation with TT has no effect on IL-6 and hs-CRP, but may be effective on the reduction of muscle damage enzymes CPK and LDH following high-intensity circuit RE.

Effects of Rhodiola rosea and Panax ginseng on the Metabolic Parameters of Rats Submitted to Swimming

Adaptogen-based plant formulations play an important role in traditional medicine and have been used in medical practice to increase the resistance of individuals. Rhodiola rosea (RR) and Panax ginseng (PG) exhibit adaptogenic properties and are related to the recovery of homeostasis and strengthen systems impaired by stress. This study aimed to evaluate the effects of RR and PG on metabolic profile and muscle damage parameters in Wistar rats submitted to swimming. Animals were divided according to the following: G1: control group; G2: group that was submitted to swimming; G3: group treated with PG; G4: group treated with PG and submitted to swimming; G5: treated with RR; and G6: treated with RR and submitted to swimming. At the end of the experimental protocol, groups G2, G4, and G6 practiced swimming for a period five times longer than during the previous 30 days. Anthropometric and biochemical parameters were investigated, and no significant results were found in the groups. Nevertheless, animals treated with PG and RR reduced the levels of creatine phosphokinase (CPK) and lactic dehydrogenase (LDH). Our findings demonstrate that both PG and RR produced a significant reduction in the levels of CPK and LDH after physical stress, suggesting that they can be used to improve physical performance. For these reasons, we may say that these plants may be used to minimize the stress promoted by the practice of physical exercises.

Benign Acute Childhood Myositis: A Benign Disease that Mimics More Severe Neuromuscular Disorder

Context:

Proximal lower limb weakness presenting acutely with or without preceding fever is a strong mimic of Guillain–Barré 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.

Daptomycin dosing in obese patients: analysis of the use of adjusted body weight versus actual body weight

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.

Twelve cases of exertional rhabdomyolysis in college football players from the same institution over a 23-year span: a descriptive study

BACKGROUND

Rhabdomyolysis is a syndrome characterized by muscle necrosis that leads to release of the intracellular contents of muscle cells into the systemic circulation. Rhabdomyolysis due to overexertion is an uncommon but well-known severe complication of strenuous activity. Exertional rhabdomyolysis (ER) is typically described in weight lifters and military recruits undergoing basic training. Few cases have been reported in football players without known predisposing risk factors. We report our experience with this condition in college football players in a single institution.

MATERIALS AND METHODS

College football players hospitalized for heat illness complicated by rhabdomyolysis were identified over a 23-year period. Clinical and laboratory findings were collected. Clinical course was recorded.

RESULTS

Twelve patients were identified. All were Black males. One had sickle cell trait. BMI averaged 33 kg/m² (range 23-45 kg/m²). Peak creatine phosphokinase (CPK) averaged 14,850 IU/L (range 1,021-109,616 IU/L). Serum creatinine averaged 1.9 mg/dl (range 1.2-3.1 mg/dl). Ten of twelve cases occurred in August. All responded to intravenous hydration with normalization of CPK and renal function. All returned to football.

CONCLUSIONS

ER is a serious complication of strenuous physical activity that can threaten renal function. ER tends to occur in August, which coincides with the start of football practice when athletes are more likely to be detrained. The condition can occur in Black athletes in the absence of sickle cell trait. ER carries a good prognosis when recognized early and treated adequately.

Creatine kinase in the U.S. population: Impact of demographics, comorbidities, and body composition on the normal range

BACKGROUND

Creatine kinase (CK) values are a critical part of the workup of suspected myopathies and are often assessed in patients that develop myalgia on statin therapy. CK elevations may influence the initiation and cessation of statin treatment, and incidentally discovered CK elevation may lead to further testing. A number of factors influence CK levels in healthy patients, but current reference ranges do not incorporate important influencers of CK such as race. Objectives of this study were to evaluate clinical factors associated with CK among healthy individuals and to develop practical reference ranges for important subgroups to improve test interpretation.

METHODS

CK was evaluated in nonpregnant participants ≥20 years old from the cross-sectional National Health and Nutrition Examination Survey (NHANES) 2011-2014. Linear and logistic regression stratified by sex identified clinical factors associated with CK levels. Adjustment for anthropomorphic measures assessed whether age and race-ethnicity differences in CK were explained by differences in body composition. The 95th and 97.5th percentiles of CK in sex/race-ethnicity subgroups were calculated, excluding patients with recent strenuous exercise.

RESULTS

A total of 10,096 nonpregnant adults were studied. Black race was strongly associated with CK. The odds ratio of having an abnormal CK for black women was 5.08 (95% CI 3.65-7.08) and for black men was 8.39 (95% CI 6.11-11.52). CK was substantially lower in older men. Differences in CK by age but not race-ethnicity were largely explained by body composition. Women with low body mass index were less likely to have an elevated CK, and overweight or obese men had an almost 2-fold greater odds of having an elevated CK. The 97.5th percentile of CK was 382 (95% CI 295-469) in white men, 1001 (95% CI 718-1284) in black men, 295 (95% CI 216-374) in white women, and 487 (95% CI 310-664) in black women.

CONCLUSION

CK is substantially higher in men and in black patients. Differences in body size and composition are also important but do not explain racial differences in CK. The 95th and 97.5th percentiles in sex and race-ethnicity subgroups provide a practical guide for clinicians interpreting CK values.

Nivolumab for the treatment of malignant melanoma in a patient with pre-existing myasthenia gravis

A 79-year-old man with lymph node recurrence of malignant melanoma received nivolumab, an anti-programmed death 1 (PD-1) monoclonal antibody. He had pre-existing ocular myasthenia gravis (MG) and a continued small amount of corticosteroid. Grade 3 creatine phosphokinase elevation appeared after two doses of nivolumab, and the treatment was postponed until it improved to grade 1. After three doses of nivolumab, he experienced diplopia and facial muscle weakness which were consistent with an acute exacerbation of MG, and the symptoms relieved without additional treatment for MG. He achieved shrinkage of metastasis after ten doses of nivolumab. Although a case who died due to MG after administration of nivolumab was reported recently, pre-existing MG is considered not to be always a contraindication of nivolumab.

Supplementation with a polyphenolic blend improves post-exercise strength recovery and muscle soreness

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.

Myoglobin cast nephropathy in a kidney transplant patient with normal creatine kinase

Delayed graft function in kidney transplant recipients is a known complication associated with increased risk of acute rejection and reduced transplant survival after 1 year. There are multiple risk factors, including prolonged cold ischemia time, donor age, and cause of donor's death. Major causes of delayed graft function are acute kidney injury in the donor, often from prolonged terminal ischemia, reflected by acute tubular injury in the recipient. However, the differential diagnosis of delayed graft function includes acute rejection, recurrence of the primary glomerular diseases, and other less commonly encountered conditions. A transplant kidney biopsy usually is required to elucidate the correct cause and initiate the right treatment, which is crucial for transplant survival. We report a case of a transplant recipient who developed delayed graft function due to an uncommon cause. After correct diagnosis, the patient's transplant function improved.

Elevated serum creatine phosphokinase is associated with mortality and inotropic requirement in critically injured adults

BACKGROUND

Hemeproteins such as free myoglobin can undergo autoxidation and catalyse lipid peroxidation, increasing oxidative stress. Creatine phosphokinase (CPK) elevation is a marker for free myoglobin after myocyte damage. Since oxidative injury is a key mechanism of injury-related organ dysfunction, we hypothesised that serum CPK levels correlate with mortality and need for inotropic medication and duration of inotropic support, i.e. shock, among critically injured patients.

METHODS

We conducted a retrospective review of 17,847 patients admitted to a single Trauma Intensive Care Unit over 9 years. 2583 patients with serum CPK levels were included in the analysis. Patient data were collected continuously into an electronic ICU repository. Univariate analysis was accomplished using Spearman correlation and the Mann–Whitney U test. Propensity score adjustment models accounting for potential confounders were used to assess the independent effect of CPK level on mortality, need for inotropic support, and duration of inotropic support.

RESULTS

Median CPK was significantly higher in patients who died (916 [IQR 332, 2472] vs. 711 [253, 1971], p = 0.004) and in those who required inotropic medications (950 [353, 2525] vs. 469 [188, 1220], p < 0.001). After adjusting for propensity score and potential confounders the odds of mortality increased by 1.10 (95% CI 1.02–1.19, p = 0.020) and the odds of inotropic medication use increased by 1.30 (95% CI 1.22–1.38, p < 0.001) per natural log unit increase in CPK. There was a significant association between CPK level and duration of inotropic support (Spearman's rho .237, p < 0.001) that remained significant in a propensity score-adjusted model.

CONCLUSION

In critically injured patients, elevated serum CPK level is independently associated with mortality, need for inotropic medication, and duration of inotropic support. This study is the first to evaluate the relationship of CPK level and mortality in addition to surrogate measures of shock in a population of critically injured patients. If these associations are verified prospectively, there may be a role for treatment with hemeprotein reductants, such as paracetamol, to mitigate the effects of shock and end-organ dysfunction.

Prevention of amiodarone-induced cardiac toxicity in male BALB/c mice by a nutrient mixture

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, cardiovascular 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.

Evaluation of impact of statin use on development of CPK elevation during daptomycin therapy

BACKGROUND

Because both daptomycin and statins may increase creatine phosphokinase (CPK) levels, the manufacturer of daptomycin suggests considering holding statins during daptomycin therapy. Published evidence suggests potential detrimental effects of withdrawing statin therapy.

OBJECTIVES

The objectives of this study were to determine the impact of concurrent statin therapy on peak CPK values, incidence of CPK elevation in patients receiving daptomycin therapy, and clinical factors associated with increased risk of developing CPK elevation.

METHODS

This was a single-center, retrospective cohort study of patients ≥18 years of age who received daptomycin for ≥72 hours and had ≥1 follow-up CPK during a 5-year period. A Kaplan-Meier curve was used to evaluate time to CPK elevation. Cox regression analyses were used to compare the risk of developing elevated CPK between 3 study groups: those receiving daptomycin alone, daptomycin with concurrent statin therapy, and statin therapy held while on daptomycin.

RESULTS

498 patients were included in the study-384 received daptomycin alone, 63 received daptomycin concurrent with statin, and 51 with statin held during daptomycin therapy. Cumulative incidence of CPK elevation was 5.1% and 12% at 7 and 14 days. Those on daptomycin and statin concurrent therapy demonstrated an approximately 2-fold risk of CPK elevation compared with those having their statin therapy held, but the overall group effect was not statistically significant (P = .17).

CONCLUSIONS

Our findings suggest that holding statin during daptomycin therapy may not be necessary, but may indicate need for increased frequency of CPK monitoring when these medications are used concurrently.

High-dose, short-interval daptomycin regimen was safe and well tolerated in three patients with chronic renal failure

BACKGROUND

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.

Advances in the studies of roles of Rho/Rho-kinase in diseases and the development of its inhibitors

RhoA/Rho-kinase pathway plays a pivotal role in numerous fundamental cellular functions including contraction, motility, proliferation, differentiation and apoptosis. The pathway is also involved in the development of many diseases such as vasospasm, pulmonary hypertension, cancer and central nervous systems (CNS) disorders. The inhibitors of Rho kinase have been extensively studied since the Rho/Rho-kinase pathway was verified as a target for a number of diseases. Herein, we reviewed the advances in the studies of the roles of Rho/Rho-kinase in diseases and the development of Rho-kinase inhibitors in recent five years.

Effect of nicorandil and amlodipine on bio-chemical parameters during isoproterenol induced myocardial necrosis in rats

OBJECTIVE

To investigate the protective effect of nicorandil and amlodipine in isoproterenol induced myocardial necrosis in rats.

METHODS

The effect of nicorandil and amlodipine on bio-chemical parameters during isoproterenol induced myocardial necrosis in rats was examined by determining the activity of creatine phosphokinase (CK), lactate dehydrogenase (LDH), and transaminases (AST, ALT) in the serum of the animals.

RESULTS

Isoproterenol (150mg/kg/day) administered rats showed statistically significant rise in activities of LDH(1.02±0.19 to 1.85±0.05), CK(4.3±0.19 to 7.37±.27), AST(0.38±.03 to 0.78±.05) and ALT(0.19±.017 to 0.346±.027) in the serum. Pre-co-treatment of rats with nicorandil and amlodipine significantly lowered the raised levels of these enzymes and thereby restoring the enzyme activity to near normal as was clear from the chart i.e. LDH was 1.10±0.04, CK was 4.37±0.19, AST and ALT were 0.39±0.028 and 0.199±0.04 respectively.

CONCLUSION

It is demonstrated that pre-co-treatment with nicorandil and amlodipine either alone or in combination help in providing protective effect on isoproterenol induced myocardial necrosis.

Serum creatine phosphokinase: a probable marker of severity in organophosphorus poisoning

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.

Sex and menopausal status influence human dietary requirements for the nutrient choline

BACKGROUND

Although humans require dietary choline for methyl donation, membrane function, and neurotransmission, choline can also be derived from the de novo synthesis of phosphatidylcholine, which is up-regulated by estrogen. A recommended Adequate Intake (AI) exists for choline; however, an Estimated Average Requirement has not been set because of a lack of sufficient human data.

OBJECTIVE

The objective of the study was to evaluate the dietary requirements for choline in healthy men and women and to investigate the clinical sequelae of choline deficiency.

DESIGN

Fifty-seven adult subjects (26 men, 16 premenopausal women, 15 postmenopausal women) were fed a diet containing 550 mg choline x 70 kg(-1) x d(-1) for 10 d followed by <50 mg choline x 70 kg(-1) x d(-1) with or without a folic acid supplement (400 microg/d per randomization) for up to 42 d. Subjects who developed organ dysfunction during this diet had normal organ function restored after incremental amounts of choline were added back to the diet. Blood and urine were monitored for signs of toxicity and metabolite concentrations, and liver fat was assessed by using magnetic resonance imaging.

RESULTS

When deprived of dietary choline, 77% of men and 80% of postmenopausal women developed fatty liver or muscle damage, whereas only 44% of premenopausal women developed such signs of organ dysfunction. Moreover, 6 men developed these signs while consuming 550 mg choline x 70 kg(-1) x d(-1), the AI for choline. Folic acid supplementation did not alter the subjects' response.

CONCLUSION

Subject characteristics (eg, menopausal status) modulated the dietary requirement for choline, and a daily intake at the current AI was not sufficient to prevent organ dysfunction in 19 of the subjects.

Professional athletes suffering from familial hypercholesterolaemia rarely tolerate statin treatment because of muscular problems

AIMS

Muscular problems are the major group of side-effects during statin treatment. They are known to occur much more frequently during and after exercise.

METHODS AND RESULTS

For the last 8 years we have monitored 22 professional athletes in whom, because of familial hypercholesterolaemia, treatment with different statins was attempted. Only six out of the 22 finally tolerated at least one member of this family of drugs. In three of these six the first statin prescribed allowed training performance without any limitation. Changing the drug demonstrated that only two tolerated all the four or five statins examined (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin). Cerivastatin was not among the statins prescribed.

CONCLUSIONS

These findings indicate that in top sports performers only about 20% tolerate statin treatment without side-effects. Clinical decision making as to lipid lowering therapy thus becomes a critical issue in this small subgroup of patients.

Professional athletes suffering from familial hypercholesterolaemia rarely tolerate statin treatment because of muscular problems

AIMS

Muscular problems are the major group of side-effects during statin treatment. They are known to occur much more frequently during and after exercise.

METHODS AND RESULTS

For the last 8 years we have monitored 22 professional athletes in whom, because of familial hypercholesterolaemia, treatment with different statins was attempted. Only six out of the 22 finally tolerated at least one member of this family of drugs. In three of these six the first statin prescribed allowed training performance without any limitation. Changing the drug demonstrated that only two tolerated all the four or five statins examined (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin). Cerivastatin was not among the statins prescribed.

CONCLUSIONS

These findings indicate that in top sports performers only about 20% tolerate statin treatment without side-effects. Clinical decision making as to lipid lowering therapy thus becomes a critical issue in this small subgroup of patients.

Growth in the reindeer

The growth of the reindeer from birth to adulthood is cumulative consisting of a rapid weight accretion during summers followed by a weight loss or stasis during winters. The birth weight of the newborn calves is about 5.3 kg. The peri- and neonatal growth rate is rather high, with a greatest individual daily weight gain as high as 400 g. The polynomial growth curve and its first order time derivative of calves show a deceleration of weight gain towards the autumn. The weight of calves at an age of 10 months was 36 to 40 kg. Adult body weight is reached by females at an age of 3 to 4 years and by males on average a year later. Serum alkaline phosphatase activity showed a negative linear correlation with age and weight in calves and it was highest both in calves and adults in summer. The creatine Phosphokinase activity in both calves and adults was higher in summer than in other seasons. Serum inorganic phosphorus was highest in the growing calves. On the other hand serum thyroxine (T4), blood glucose and calcium did not show significant age-dependent or seasonal variations.