Creatine Phosphokinase Levels Research Articles

Clinical utility of anti-Ro52 antibody confirmation in anti-MDA5 antibody-positive dermatomyositis: A Case Report.

This case report highlights dermatomyositis (DM) characterized by the concurrent presence of anti-melanoma differentiation-associated protein 5 (anti-MDA5) and anti-Ro52 antibodies. A 64-year-old woman initially presented with erythema on the palms, which later spread to the dorsum of the hands, followed by involvement of the face, forehead, and upper eyelids. The patient reported joint pain, fatigue, and dyspnea. Physical examination revealed characteristic cutaneous manifestations, including heliotrope rash and Gottron's sign, accompanied by skin ulceration and muscle weakness. Blood tests showed elevated levels of creatine phosphokinase and C-reactive protein. A high-resolution computed tomography (HRCT) scan revealed interstitial lung disease (ILD) with an organizing pneumonia (OP) pattern. Magnetic resonance imaging (MRI) confirmed the presence of myositis. Autoantibody analysis revealed concurrent positivity for both anti-MDA5 and anti-Ro52 antibodies. At the time of diagnosis, she had no respiratory impairment, but had an elevated C-reactive protein and high levels of anti-MDA5 antibody. She was started on triple combination therapy with glucocorticoids, cyclophosphamide, and tacrolimus. She had worsening oxygenation and elevated ferritin during the first weeks of treatment, but then her symptoms improved. Early detection of a co-positive anti-Ro52 antibody led to early initiation of triple combination therapy and a good prognosis.

Assessment of cardiac adverse events following COVID-19 vaccination by speckle tracking echocardiography

Cardiac discomfort has been reported periodically in COVID-19-vaccinated individuals. Thus, this study aimed to evaluate the role of myocardial strains in the early assessment of the clinical presentations after COVID-19 vaccination. Totally, 121 subjects who received at least one dose of vaccine within 6 weeks underwent laboratory tests, electrocardiogram (ECG), and echocardiogram. Two-dimensional speckle tracking echocardiography (2D-STE) was implemented to analyze changes in the left ventricular myocardium. After vaccination, 66 individuals (55.4 ± 17.4 years) developed cardiac discomforts, such as chest tightness, palpitations, dyspnea, and chest pain. The ECG readings exhibited both premature ventricular contractions and premature atrial contractions (n = 24, 36.4%), while none of the individuals in the control group manifested signs of cardiac arrhythmia. All had normal serum levels of creatine phosphokinase, creatine kinase myocardial band, troponin, N-terminal pro b-type natriuretic peptide, platelets, and D-dimer. Left ventricular ejection fraction in the symptomatic group (71.41% ± 7.12%) and the control group (72.18% ± 5.11%) (p = 0.492) were normal. Use of 2D-STE presented global longitudinal strain (GLS) and global circumferential strain (GCS) was reduced in the symptomatic group (17.86% ± 3.22% and 18.37% ± 5.22%) compared to the control group (19.54% ± 2.18% and 20.73% ± 4.09%) (p = 0.001 and p = 0.028). COVID-19 vaccine-related cardiac adverse effects can be assessed early by 2D-STE. The prognostic implications of GLS and GCS enable the evaluation of subtle changes in myocardial function after vaccination.

Ejection Fraction-Related Differences of Baseline Characteristics and Outcomes in Troponin-Positive Patients without Obstructive Coronary Artery Disease

Background: The development and course of myocardial infarction with non-obstructive coronary artery (MINOCA) disease is still not fully understood. In this study, we aimed to examine the baseline characteristics of in-hospital outcomes and long-term outcomes of a cohort of troponin-positive patients without obstructive coronary artery disease based on different left ventricular ejection fractions (LVEFs). Methods and results: We included a cohort of 254 patients (mean age: 64 (50.8–75.3) years, 120 females) with suspected myocardial infarction and no obstructive coronary artery disease (MINOCA) in our institutional database between 2010 and 2021. Among these patients, 170 had LVEF ≥ 50% (84 females, 49.4%), 31 patients had LVEF 40–49% (15 females, 48.4%), and 53 patients had LVEF < 40% (20 females, 37.7%). The mean age in the LVEF ≥ 50% group was 61.5 (48–73) years, in the LVEF 40–49% group was 67 (57–78) years, and in the LVEF < 40% group was 68 (56–75.5) years (p = 0.05). The mean troponin value was highest in the LVEF < 40% group, at 3.8 (1.7–4.6) µg/L, and lowest in the LVEF ≥ 50% group, at 1.1 (0.5–2.1) µg/L (p = 0.05). Creatine Phosphokinase (CK) levels were highest in the LVEF ≥ 50% group (156 (89.5–256)) and lowest in the LVEF 40–49% group (127 (73–256)) (p < 0.05), while the mean BNP value was lowest in the LVEF ≥ 50% group (98 (48–278) pg/mL) and highest in the <40% group (793 (238.3–2247.5) pg/mL) (p = 0.001). Adverse in-hospital cardiovascular events were highest in the LVEF < 40% group compared to the LVEF 40–49% group and the LVEF ≥ 50% group (56% vs. 55% vs. 27%; p < 0.001). Over a follow-up period of 6.2 ± 3.1 years, the all-cause mortality was higher in the LVEF < 40% group compared to the LVEF 40–49% group and the LVEF ≥ 50% group. Among the different factors, LVEF < 40% and LVEF 40–49% were associated with an increased risk of in-hospital cardiovascular events in the multivariable Cox regression analysis. Conclusions: LVEF has different impacts on in-hospital cardiovascular events in this cohort. Furthermore, LVEF influences long-term all-cause mortality.

Severe course of leptospirosis (clinical case)

The article describes a clinical case of severe leptospirosis. Patient K., was admitted to the neurosurgical department on 26.11.2023 with a diagnosis of «Closed craniocerebral injury dated 22.11.2023. Severe brain injury. Linear fracture of the occipital bone. Eyelid hematoma. An abrasion of the upper eyelid on the right». On 29.11.2023, an objective examination drew attention to an increase in body temperature to 39.50 C, subictericity of the sclera and skin, conjunctival injections. There is a hemorrhagic rash on the skin of the trunk and limbs. Hemodynamics is unstable, episodes of arterial hypotension. Laboratory examination revealed mild anemia, signs of hepatic-renal insufficiency, hyperbilirubinemia, increased concentrations of creatine phosphokinase, C-reactive protein, procalcitonin. Hepatic-renal insufficiency increased in dynamics, the level of creatine phosphokinase and procalcitonin increased. Additionally, the differential diagnostic search was aimed at identifying infectious diseases: hemorrhagic fever with renal syndrome, leptospirosis, malaria, viral hepatitis. Immunoglobulins of class M to Leptospira interrogans were detected (11.12.2023). The patient received antibacterial therapy, extracorporeal detoxification operations, artificial ventilation, infusion therapy, correction of the hemostasis system were performed in parallel. Against the background of complex treatment, the patient's condition was stabilized, and the patient was discharged from the hospital on 61 days with restoration of health.

Carnitine palmitoyltransferase II (CPT II) deficiency responsible for refractory cardiac arrhythmias, acute multiorgan failure and early fatal outcome

BackgroundCarnitine palmitoyltransferase II (CPT II) deficiency is a rare inborn error of mitochondrial fatty acid metabolism with autosomal recessive pattern of inheritance. Its phenotype is highly variable (neonatal, infantile, and adult onset) on the base of mutations of the CPT II gene. In affected subjects, long-chain acylcarnitines cannot be subdivided into carnitine and acyl-CoA, leading to their toxic accumulation in different organs. Neonatal form is the most severe, and all the reported patients died within a few days to 6 months after birth. Hereby, we report on a male late-preterm newborn who presented refractory cardiac arrhythmias and acute multiorgan (hepatic, renal, muscular) injury, leading to cerebral hemorrhage, hydrocephalus, cardiovascular failure and early (day 5 of life) to death. Subsequently, extended metabolic screening and target next generation sequencing (NGS) analysis allowed the CPT II deficiency diagnosis.Case presentationThe male proband was born at 36+ 4 weeks of gestation by spontaneous vaginal delivery. Parents were healthy and nonconsanguineous, although both coming from Nigeria. Family history was unremarkable. Apgar score was 9/9. At birth, anthropometric measures were as follows: weight 2850 g (47th centile, -0.07 standard deviations, SD), length 50 cm (81st centile, + 0.89 SD) and occipitofrontal circumference (OFC) 35 cm (87th centile, + 1.14 SD). On day 2 of life our newborn showed bradycardia (heart rate around 80 bpm) and hypotonia, and was then transferred to the Neonatal Intensive Care Unit (NICU). There, he subsequently manifested many episodes of ventricular tachycardia, which were treated with pharmacological (magnesium sulfate) and electrical cardioversion. Due to the critical conditions of the baby (hepatic, renal and cardiac dysfunctions) and to guarantee optimal management of the arrythmias, he was transferred to the Pediatric Cardiology Reference Center of our region (Sicily, Italy), where he died 2 days later. Thereafter, the carnitines profile evidenced by the extended metabolic screening resulted compatible with a fatty acid oxidation defect (increased levels of acylcarnitines C16 and C18, and low of C2); afterwards, the targeted next generation sequencing (NGS) analysis revealed the known c.680 C > T p. (Pro227Leu) homozygous missense mutation of the CPTII gene, for diagnosis of CPT II deficiency. Genetic investigations have been, then, extended to the baby’s parents, who were identified as heterozygous carriers of the same variant. When we meet again the parents for genetic counseling, the mother was within the first trimester of her second pregnancy. Therefore, we offered to the couple and performed the prenatal target NGS analysis on chorionic villi sample, which did not detect any alterations, excluding thus the CPT II deficiency in their second child.ConclusionsCPTII deficiency may be suspected in newborns showing cardiac arrhythmias, associated or not with hypertrophic cardiomyopathy, polycystic kidneys, brain malformations, hepatomegaly. Its diagnosis should be even more suspected and investigated in cases of increased plasmatic levels of creatine phosphokinase and acylcarnitines in addition to kidney, heart and liver dysfunctions, as occurred in the present patient. Accurate family history, extended metabolic screening, and multidisciplinary approach are necessary for diagnosis and adequate management of affected subjects. Next generation sequencing (NGS) techniques allow the identification of the CPTII gene mutation, essential to confirm the diagnosis before or after birth, as well as to calculate the recurrence risk for family members. Our report broads the knowledge of the genetic and molecular bases of such rare disease, improving its clinical characterization, and provides useful indications for the treatment of patients.

Identification of patients with orfan pathology as a result of routine creatine phosphokinase level analysis. The experience of the Krasnoyarsk Territory

Background. Duchenne muscular dystrophy (DMD) is a severe genetic disease that usually affects boys and it is characterized by a gradual loss of muscle strength up to respiratory arrest from the childhood. Currently, there are several types of successful pathogenic therapies for the disease, but it is most effective before the age of 5 years. Thereby, the problem of verifying the diagnosis before the treatment fails to work (when treatment can still make the patient’s life easier) becomes urgent. In the Russian Federation only about 1,500 boys are diagnosed with DMD, when the calculated value is 3,500.Aim. To identify all cases of DMD among patients in the neurological departments of hospitals in the Krasnoyarsk region by measuring the level of creatine phosphokinase.Materials and methods. This study was estimated by neurologists in the Krasnoyarsk Interdistrict Children’s Clinical Hospital No. 1 and the Krasnoyarsk Regional Clinical Center for Maternal and Child Health. When elevated levels of creatine phosphokinase were detected in children, genetic analysis was performed to verify DMD.Results and conclusion. Innovate experience of Krasnoyarsk region made it possible to identify all patients with DMD in the neurological departments of the Krasnoyarsk Interdistrict Children’s Clinical Hospital No. 1 and the Krasnoyarsk Regional Clinical Center for Maternal and Child Health using cheap creatine phosphokinase level analysis. The number of patients diagnosed with DMD is now ~4 cases per year. As a result, there is a correspondence between the number of real patients and the epidemiological estimate quantity for the Krasnoyarsk region.

Efficacy of Melatonin as an Adjunctive Therapy in Hospitalized Patients with Mild to Moderate COVID-19: A Randomized, Double-blind Clinical Trial

Background: Melatonin has proven antioxidant and anti-inflammatory properties that may address the pathophysiology of coronavirus disease 2019 (COVID-19). Therefore, the current study was conducted to evaluate the safety and efficacy of melatonin in COVID-19. Methods: In this single-center, randomized, double-blind, placebo-controlled clinical trial, 96 adults hospitalized with mild to moderate COVID-19 were recruited. The participants were allocated into the melatonin and the placebo groups, randomly (1:1 ratio). Results: The primary outcomes were a reduction in the length of hospital stay, the rate of ICU admissions, intubation/mechanical ventilation, and mortalities within 14 days of starting the treatment compared to the placebo group. After two weeks of follow-up, the blood oxygen saturation and the respiratory rate significantly improved in the melatonin group. C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, creatine phosphokinase, Ferritin, and D-dimer levels were significantly decreased in the melatonin group. Conversely, these markers were considerably increased in the placebo group. These serum marker levels also showed a significant difference in between- group comparison. The comparison of clinical endpoints between the two groups showed no significant difference. Conclusion: This clinical trial study indicated that the combination of oral melatonin tablets and standard treatment could substantially improve blood oxygen saturation and inflammatory factors in mild to moderate hospitalized COVID-19 patients.

High protein-low carbohydrate diet can improve hypoxia tolerance of triploid rainbow trout (Oncorhynchus mykiss): Effects on physiological and metabolic responses to acute hypoxia

Triploid rainbow trout is a hypoxia-sensitive fish species, and is susceptible to death in summer with high water temperature induced acute hypoxia. The study was conducted to evaluate the effect of high protein diet and high carbohydrate diet on hypoxic tolerance of triploid rainbow trout. Two isolipidic and isoenergetic diets with low protein-high carbohydrate level (LPHC) and high protein-low carbohydrate level (HPLC) were specifically formulated. After the feeding trial with 80 days, two group fish were treated with acute hypoxic challenge. Plasma biochemical parameters, hepatic anti-stress, antioxidant and immune related genes expression, and hepatic glucose, lipid, protein and amino acid metabolism related genes expression were then analyzed. The results showed that compared with HPLC diet, LPHC diet could result in excessive plasma levels of alanine aminotransferase (ALT; 36.3 VS 14.0 U/L), aspartate aminotransferase (AST; 978 VS 366 U/L), alkaline phosphatase (ALP; 374 VS 204 U/L), creatine phosphokinase (CPK; 7538 VS 4937 U/L) and lactate dehydrogenase (LDH; 940 VS 451 U/L). In addition, HPLC diet could remodel metabolism of glucose, lipid and protein based on the mRNA expression levels of the genes regulating glycometabolism, lipometabolism, and protein and amino acids metabolism. HPLC diet also enhanced the mRNA expression levels of the genes regulating anti-stress (HSP70, HIF-1a and HIF-2a), antioxidant (Nrf2, SOD, CAT, GPx and HO-1) and immune (IFN-γ, IL-1β, TNF-α and IL-8). In total, LPHC diet could aggravate hypoxic stress of triploid rainbow trout, while HPLC diet could improve fish hypoxic tolerance.

Cardioprotective role of royal jelly in the prevention of celecoxib-mediated cardiotoxicity in adult male albino rats

BackgroundCelecoxib, a cyclooxygenase-2 selective inhibitor non-steroidal anti-inflammatory drugs, is used for the management of short- and long-term pain as well as in other inflammatory conditions. Unfortunately, its chronic use is highly associated with serious abnormal cardiovascular events. The current study was designed to explore the effect of long-term administration of celecoxib on the cardiac tissues of male albino rats. The study also examined the alleged cardioprotective effect of royal jelly.MethodsThirty, male albino rats were randomly divided into 3 equal groups; 10 each: (1) rats served as the control group and received no drug; (2) rats received celecoxib (50 mg/kg/day, orally), for 30 consecutive days; (3) rats received celecoxib (50 mg/kg/day, orally) plus royal jelly (300 mg/kg/day, orally) for 30 consecutive days. Sera were collected to assay cardiac enzymes and oxidant/antioxidant status. Rats were euthanatized and cardiac tissues were dissected for quantitative estimation of apoptotic genes (Bax) and anti-apoptotic gene (Bcl-2).ResultsLong-term celecoxib administration caused cardiotoxicity in male albino rats as manifested by significant elevation of serum levels of creatine phosphokinase (CPK), creatine kinase-MB (CK-MB), and lactate dehydrogenase (LDH), with ameliorative effects of royal jelly against celecoxib-induced cardiotoxicity as manifested by significantly decrease in serum CPK, CK-MB, and LDH levels. It also showed a significant decrease in the oxidative stress indicator malondialdehyde (MDA) levels and the bax gene. Additionally, it demonstrated significant increases in the bcl-2 gene and superoxide dismutase (SOD) levels, which contribute to its therapeutic effects against celecoxib-induced cardiotoxicity.ConclusionLong-term celecoxib administration caused cardiotoxicity in male albino rats with protective effect of royal jelly being given together. It could be concluded that royal jelly may prove a useful adjunct in patients being prescribed celecoxib.Trial registrationNot applicable.

Fulminant myocarditis during postoperative adjuvant chemotherapy for lung cancer with atezolizumab: a case report

BackgroundPostoperative adjuvant systemic therapy with atezolizumab for lung cancer has been reported to be effective. Although myocarditis is a rare immune adverse event associated with atezolizumab, it can have a serious course and should be treated with caution. We herein report a case of fulminant myocarditis during adjuvant systemic therapy with atezolizumab.Case presentationThe patient was a 49-year-old Asian woman. She was diagnosed with pT2aN1M0 stage IIB (Programmed Death Ligand 1(PD-L1), 50%) after surgery for right upper lobe lung adenocarcinoma. Atezolizumab was administered following platinum-based adjuvant chemotherapy. On day 14, the patient was hospitalized because of deterioration in her general condition caused by fever. On day 16, she developed dyspnea, which worsened, and on day 17, she experienced shock. Blood tests, echocardiography, and cardiac catheterization were performed, and the patient was diagnosed with cardiogenic shock due to myocarditis. Initial measures did not improve the patient’s shock state. The patient was transferred to hospital for the use of an assistive circulatory system. Pulse steroid therapy was administered, and myocarditis showed a tendency toward improvement. A retrospective review of the patient’s history revealed a decreased lymphocyte count and an increase in the neutrophil/lymphocyte ratio, which may be useful for detecting severe immune-related adverse events. The troponin levels were elevated, but creatine phosphokinase level remained within the normal range.ConclusionMyocarditis can be fatal due to the rapid progression of symptoms. Close follow-up, a prompt diagnosis, and therapeutic intervention are important. Decreased lymphocyte counts, increased neutrophil/lymphocyte ratios, and the measurement of multiple myocardial biomarkers are considered useful for the early diagnosis of myocarditis.

The effect of C60 fullerenes on the recovery of muscle soleus contraction dynamics in rats after chronic alcoholization

Background. It has been shown that the available therapeutic agents do not eliminate the consequences of miotic pathologies in chronic alcoholism, the most significant of which are disturbances in the dynamics of muscle contraction. A positive effect of biocompatible water-soluble C60 fullerenes on the contraction parameters of damaged muscles has been established. In addition, administration of C60 fullerene aqueous solution during chronic alcoholization of rats protects muscle tissue from damage caused by oxidative stress. Materials and Methods. Biomechanical parameters such as the values of the minimum and maximum contraction force and the muscle force impulse were evaluated using tensometry. The blood levels of creatine phosphokinase and lactate dehydrogenase, creatinine and lactate as well as the level of oxidative processes in muscle tissue of experimental animals (content of hydrogen peroxide, activity of catalase, glutathione peroxidase and superoxide dismutase) as markers of muscle damage were determined using methods of biochemical analysis. Results. The C60 fullerene aqueous solution effect on the skeletal muscle contraction dynamics in rats after chronic alcoholization for 9 months and cessation of alcohol consumption for 1 month was investigated. It was established that water-soluble C60 fullerenes (daily dose of 1 mg/kg) reduce the effects of chronic alcoholization by 35–40±2 % on the studied biomechanical parameters and by 20±1 % on the studied biochemical parameters compared to the group of alcoholized animals, thus increasing the energy capabilities of the muscular system. Conclusions. The obtained data indicate a pronounced protective effect of C60 fullerenes on the muscle soleus contraction dynamics during the development of alcoholic myopathy, which opens up the potential possibility of their use for the prevention and correction of miotic damage.

Safety and feasibility of a functional electrical stimulation cycling-based muscular dysfunction diagnostic method in mechanically ventilated patients.

A nonvolitional diagnostic method based on FES-Cycling technology has recently been demonstrated for mechanically ventilated patients. This method presents good sensitivity and specificity for detecting muscle dysfunction and survival prognosis, even in unconscious patients. As the clinical relevance of this method has already been reported, we aimed to evaluate its safety and feasibility. An observational prospective study was carried out with 20 critically ill, mechanically ventilated patients. The FES-cycling equipment was set in a specific diagnostic mode. For safety determination, hemodynamic parameters and peripheral oxygen saturation were measured before and immediately after the diagnostic protocol, as well as venous oxygen saturation and blood lactate. The creatine phosphokinase level (CPK) was measured before and 24, 48, and 72 h after the test. The time taken to carry out the entire diagnostic protocol and the number of patients with visible muscle contraction (capacity of perceptive muscular recruitment) were recorded to assess feasibility. Heart rate [91 ± 23 vs. 94 ± 23 bpm (p = 0.0837)], systolic [122 ± 19 vs. 124 ± 19 mm Hg (p = 0.4261)] and diastolic blood pressure [68 ± 13 vs. 70 ± 15 mm Hg (p = 0.3462)], and peripheral [98 (96-99) vs. 98 (95-99) % (p = 0.6353)] and venous oxygen saturation [71 ± 14 vs. 69 ± 14% (p = 0.1317)] did not change after the diagnostic protocol. Moreover, blood lactate [1.48 ± 0.65 vs. 1.53 ± 0.71 mmol/L (p = 0.2320)] did not change. CPK did not change up to 72 h after the test [99 (59-422) vs. 125 (66-674) (p = 0.2799) vs. 161 (66-352) (p > 0.999) vs. 100 (33-409) (p = 0.5901)]. The time taken to perform the diagnostic assessment was 11.3 ± 1.1 min. In addition, 75% of the patients presented very visible muscle contractions, and 25% of them presented barely visible muscle contractions. The FES cycling-based muscular dysfunction diagnostic method is safe and feasible. Hemodynamic parameters, peripheral oxygen saturation, venous oxygen saturation, and blood lactate did not change after the diagnostic protocol. The muscle damage marker (CPK) did not increase up to 72 h after the diagnostic protocol.

Real-world effectiveness and safety of baricitinib including its effect on biomarkers and laboratory data in Japanese adult patients with atopic dermatitis: a single-center retrospective study

Baricitinib demonstrated efficacy and tolerable safety in clinical trials for atopic dermatitis (AD); however, real-world data are limited. We examined effectiveness and safety of baricitinib, and laboratory data in AD patients treated with baricitinib in our department. We also evaluated baseline clinical severity in responders and non-responders. All adult AD patients treated with baricitinib in our department between January 2021 and February 2023 were included. Data on 30 Japanese AD patients were analyzed. Objective severity scores and patient-reported outcomes improved at one and 3 months, except for the affected body surface area at 1 month. The proportions of patients who achieved eczema area and severity index-50% improvement were 30.0% (9/30) at 1 month and 53.3% (16/30) at 3 months. There were no significant changes in AD biomarkers. No significant difference was observed in baseline clinical severity between responders and non-responders. No significant changes were observed in laboratory results except for increased serum creatine phosphokinase levels at 3 months. One case of herpes zoster and one case of ocular herpes were observed. Baricitinib showed mild effectiveness and favorable safety including laboratory findings. Biomarkers did not reflect clinical improvement. Further study is needed to identify characteristics of responders.

Pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient: a case report and review of the literature

BackgroundThe cardiovascular system is among the least systems affected by immune-related adverse events. We report a rare life-threatening case of pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient.Case presentationAn 82-year-old Caucasian female with invasive urothelial carcinoma, started on first-line pembrolizumab, was admitted four days after receiving her second dose for severe asthenia, diffuse muscle aches, neck pain, and lethargy. In the emergency department, she had several episodes of bradycardia reaching 40 beats per minute associated with general discomfort and fatigue. Electrocardiography showed a third-degree atrioventricular heart block, while the patient remained normotensive. Cardiac damage parameters were altered with elevated levels of creatine phosphokinase of 8930 U/L, suggestive of immune checkpoint inhibitor-induced myositis, and troponin T of 1.060 ng/mL. Transthoracic echocardiography showed a preserved ejection fraction. Pembrolizumab-induced myocarditis was suspected. Therefore, treatment was initiated with high-dose glucocorticoids for 5 days, followed by a long oral steroid taper. A pacemaker was also implanted. Treatment resulted in the resolution of heart block and a decrease in creatine phosphokinase to the normal range.ConclusionLife-threatening cardiac adverse events in the form of myocarditis may occur with pembrolizumab use, warranting vigilant cardiac monitoring. Troponin monitoring in high-risk patients, along with baseline echocardiography may help identify this complication promptly to prevent life-threatening consequences.

Pediatric kidney care experience after the 2023 Turkey/Syria earthquake.

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. A web-based software was prepared. Patient demographics, time under rubble (TUR), admission laboratory data, dialysis, and kidney and overall outcomes were asked. 903 injured children (median age: 11.62 years) were evaluated. Mean TUR was 13h (Interquartile range-IQR: 32.5), max 240h). 31 of 32 patients with a TUR of >120h survived. The patient who rescued after ten days survived.Two-thirds of the patients were given 50mEq/L sodium-bicarbonate in 0.45% sodium-chloride solution on admission day. 58% of patients were given intravenous fluid (IVF) at a volume of 2000-3000mL/m2 body surface area (BSA), 40% of 3000-4000mL/m2 BSA, and only 2% of >4000mL/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)≥20950U/L, TUR≥10h, and the first-day IVF volume<3000-4000mL/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. 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 >20950U/L, but not with death. Adolescent age and initial IVF of less than 3000-4000mL/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.

Thigh compartment syndrome: Outcomes in an urban level 1 trauma center

IntroductionThigh compartment syndrome (TCS) is a rare surgical emergency associated with a high risk of morbidity with mortality rates as high as 47 %. There is sparse literature discussing the management as well as outcomes of these injuries. The purpose of this study is to review a consecutive series of patients presenting to a single urban Level 1 trauma center with TCS to identify injury characteristics, clinical presentation, and outcomes associated with this injury. MethodsA trauma database was queried for all patients with a diagnosis of TCS at a single level 1 urban trauma center between January 1, 2011 and December 31, 2021. Demographic and injury variables collected included age, sex, BMI, mechanism of injury, and creatine phosphokinase levels (CPK). Hospital quality measures including time from admission to surgery, length of both hospital and ICU stay, complications, and cost of care were collected. Descriptive statistics are reported as median [interquartile range] or N (percent). ResultsThere were 14 patients identified with a diagnosis of TCS. All were men with an average age 33.5 [23.5 - 38] years and an average BMI of 26 [22.9–28.1]. The most common cause of injury was blunt trauma (71.4 %), and the remaining 28.6 % were gunshot wound injuries. Within the cohort, 6 (42.9 %) patients sustained a femoral shaft fracture, and 4 (28.6 %) patients sustained a vascular injury. The median initial CPK of patients within this cohort was 3405 [1232–5339] and reached a peak of 5271 [3013–13,266]. The median time from admission to diagnosis was 6.8 [0–236.9] hours. The median time from admission to the operating room was 8.2 [0.6–236.9] hours, and the median number of operating room visits was 3 [2 - 6]. Five patients (35.7 %) wounds were closed with split thickness skin grafting. There were 12 (85.7 %) patients who required ICU care. The median ICU length of stay was 7.5 days [4–15]. The median hospital length of stay was 16.5 days [13.25–38.0]. The median total charges for a patient with thigh compartment syndrome was $129,159.00 [$24,768.00 - $587,152.00]. The median direct variable cost for these patients was $86,106.00 For comparison, the median direct variable cost for patients with femur fractures without TCS at this institution was $8,497.28 [$1,903.52–$21,893.13]. No patients required readmission within 60 days. There were no mortalities. ConclusionTCS is a rare and life-threatening injury associated with significant morbidity. Despite rapid diagnosis and fasciotomy, the majority of the patients have prolonged hospital courses, ICU lengths of stay, and significant costs of treatment. Providers can reference the outcomes reported in this study when caring for TCS patients.

Clinical predictors of left ventricular thrombus after myocardial infarction as detected by magnetic resonance imaging.

The diagnosis of a left ventricular (LV) thrombus in patients with ST-segment elevation myocardial infarction (STEMI) remains challenging. The aim of the current study is to characterize clinical predictors for LV thrombus formation, as detected by cardiac magnetic resonance imaging (CMRI). We retrospectively evaluated 337 consecutive STEMI patients. All patients underwent transthoracic echocardiography (TTE) and CMRI during their index hospitalization. We developed a novel risk stratification model (ThrombScore) to identify patients at risk of developing an LV thrombus. CMRI revealed the presence of LV thrombus in 34 patients (10%), of whom 33 (97%) had experienced an anterior wall myocardial infarction (MI), and the majority (77%) had at least mildly reduced left ventricular ejection fraction (LVEF < 45%). The sensitivity for thrombus formation of the first and second TTE was 5.9% and 59%, respectively. Multivariate logistic regression model revealed that elevated C-reactive protein levels, lack of ST-segment elevation (STe) resolution, elevated creatine phosphokinase levels, and STe in anterior ECG leads are robust independent predictors for developing an LV thrombus. These variables were incorporated to construct the ThrombScore: a simple six-point risk model. The odds ratio for developing thrombus per one-point increase in the score was 3.2 (95% CI 2.1-5.01; p < 0.001). The discrimination analysis of the model revealed a c-statistic of 0.86 for thrombus development. The model identified three distinct categories (I, II, and III) with corresponding thrombus incidences of 0%, 1.6%, and 27.6%, respectively. ThrombScore is a simple and practical clinical model for risk stratification of thrombus formation in patients with STEMI.

Biological response of nonhuman primates to controlled levels of acute blood loss.

The global shortage of human blood for medical use has prompted the development of alternative blood sources. Nonhuman primates (NHPs) are commonly used owing to their physiological similarities to humans. The objective of the current study was to establish a controlled-blood-loss model in NHPs to explore their clinical and biological responses. Blood was sequentially withdrawn from 10 cynomolgus monkeys (10, 14, 18, 22, and 25% of the total blood volume); their vital signs were monitored, and blood parameters were serially analyzed. Humoral mediators in the blood were measured using flow cytometry and enzyme-linked immunosorbent assays. In NHPs subjects to 25% blood loss and presenting with related clinical symptoms, the systolic blood pressure ratio on day 0 after bleeding was significantly lower than that of the animals from the other groups (median: 0.65 vs. 0.88, P = 0.0444). Red blood cell counts from day 0-14 and hematocrit levels from day 0-7 were markedly decreased relative to the baseline (P < 0.01). These parameters showed a direct correlation with the extent of blood loss. The levels of creatine phosphokinase, aspartate aminotransferase, and alanine aminotransferase exhibited increases in response to blood loss and had a stronger correlation with the hemoglobin ratio than the volume of blood loss. The levels of C3a and C4a, as well as interleukin (IL)-1α and IL-15, displayed a strong correlation, with no apparent association with blood loss. The findings of the present study showed that only NHPs with 25% blood loss exhibited clinical decompensation and significant systolic blood pressure reduction without fatalities, suggesting that this level of blood loss is suitable for evaluating blood transfusion efficacy or other treatments in NHP models. In addition, the ratio of hemoglobin may serve as a more dependable marker for predicting clinical status than the actual volume of blood loss. Thus, our study could serve as a basis for future xenotransfusion research and to predict biological responses to massive blood loss in humans where controlled experiments cannot be ethically performed.

Factors Associated with Acute Kidney Injury Occurrence and Prognosis in Rhabdomyolysis at the Emergency Department.

Background and Objectives: This study aimed to analyze patients with rhabdomyolysis who presented to emergency departments and identify their distribution of related disease and prognostic factors. Materials and Methods: A retrospective cohort study was conducted on patients with rhabdomyolysis who presented to emergency departments over a 10-year period. Patient data, including patients' demographic variables (sex and age), mode of arrival, final diagnosis, statin use, rhabdomyolysis trigger factors, and levels of serum creatine phosphokinase (CPK), myoglobin, creatinine, sodium, potassium, phosphate, calcium, and lactate, were analyzed. Univariate and multivariate logistic regression analyses were conducted to identify the predictive factors of acute kidney injury (AKI). Results: Among the patients, 268 (65.6%) were found to have trigger factors without underlying diseases. Furthermore, 115 (28.2%) patients developed AKI. This comprehensive study sheds light on the diverse factors influencing the occurrence of AKI in rhabdomyolysis and provides insights into AKI predictive markers. Furthermore, we analyzed the cases by dividing them into six groups: occurrence of AKI, occurrence of infection, and simple or complex rhabdomyolysis. CPK time course was found to be important in clinical prognosis, such as AKI occurrence, dialysis or not, and mortality. Conclusions: Age, statin use, elevated creatinine and lactate levels, and initial serum CPK level emerged as significant predictors of AKI. CPK time course was also found to be an important factor in predicting the clinical outcomes of patients with rhabdomyolysis.

A Rare Clinical Scenario of Hypothyroid-induced Rhabdomyolysis

Abstract Muscle involvement is common in hypothyroidism and is seen in nearly 80% of the cases. However, rhabdomyolysis is a rare manifestation and is usually triggered by precipitating factors such as exercise, statins, and toxins. We describe the case of a 58-year-old woman with de novo hypothyroidism presenting with severe rhabdomyolysis requiring hemodialysis. A 58-year-old diabetic and hypertensive female was presented at our tertiary care center with symptoms of generalized weakness, difficulty in walking, and decreased urine output. Her blood investigations showed elevated creatine phosphokinase (CPK), renal parameters, and thyroid-stimulating hormone (TSH) levels suggestive of autoimmune thyroiditis with rhabdomyolysis. She was treated with thyroid hormone supplementation and hemodialysis. The patient recovered gradually with normalization of renal parameters. Although muscle involvement is common in hypothyroidism, rhabdomyolysis is a rare manifestation. Diagnosis is established by demonstrating elevated CPK and TSH levels. Management consists of hydration and thyroid hormone supplementation. Hemodialysis is required in severe cases with established acute kidney injury.