Creatinine Phosphokinase Research Articles

Acute kidney injury following rhabdomyolysis due to multiple wasp stings

Wasp stings are a common form of envenomation in tropical countries. Multiple wasp stings may cause fatal complications such as anaphylactic reactions, intravascular hemolysis, rhabdomyolysis, acute kidney injury (AKI), or even death also. Here we report a 9-year-old boy who was admitted to a tertiary care hospital in Bangladesh with complaints of multiple wasp stings all over the body 15 days back. He had oliguria and generalized edema for 7 days. The urine test was negative for red blood cells and his renal function was gradually deteriorating. His serum creatinine phosphokinase was gradually rising. Intermittent hemodialysis through a central venous catheter was started immediately. Renal biopsy revealed myoglobin cast nephropathy. On the basis of history, clinical manifestations, and laboratory investigation, he was diagnosed as AKI following rhabdomyolysis due to multiple wasp stings. Clinical and biochemical picture started to improve including urine output was normalized on seventh day of post-admission. Timely initiation of dialysis and supporting therapy can improve renal survival in case of AKI due to wasp stings.

Safety Profile of Upadacitinib up to 3 Years in Psoriatic Arthritis: An Integrated Analysis of Two Pivotal Phase 3 Trials.

IntroductionThis integrated analysis describes the safety profile of upadacitinib, an oral Janus kinase inhibitor, at 15 and 30 mg once daily for up to 3 years of exposure in patients with active psoriatic arthritis (PsA) who had a prior inadequate response or intolerance to ≥ 1 non-biologic or biologic disease-modifying antirheumatic drug.MethodsSafety data were pooled and analyzed from two randomized, placebo-controlled phase 3 trials. Both trials evaluated upadacitinib 15 mg and 30 mg once daily, and one trial also evaluated adalimumab 40 mg every other week. Treatment-emergent adverse events (TEAEs) and laboratory data were summarized for four groups: pooled placebo, pooled upadacitinib 15 mg, pooled upadacitinib 30 mg, and adalimumab. TEAEs were reported as exposure-adjusted event rates (events per 100 patient-years [E/100 PY]) up to a data cut-off of June 29, 2020.ResultsA total of 2257 patients received ≥ 1 dose of upadacitinib 15 mg (N = 907) or 30 mg (N = 921) for 2504.6 PY of exposure or adalimumab (N = 429) for 549.7 PY of exposure. Upper respiratory tract infection, nasopharyngitis, and increased creatine phosphokinase (CPK) were the most common TEAEs with upadacitinib. Rates of malignancies, adjudicated major adverse cardiovascular events (MACEs) and venous thromboembolic events (VTEs), and deaths were similar across treatment groups. Rates of herpes zoster (HZ) and opportunistic infections (OI; excluding tuberculosis, HZ, and oral candidiasis) were higher with upadacitinib versus adalimumab. Serious infection, anemia, and CPK elevations were most frequent with upadacitinib 30 mg. Potentially clinically significant laboratory abnormalities were uncommon.ConclusionsUpadacitinib 15 mg and adalimumab had similar safety profiles with the exception of HZ and OIs, consistent with what was observed in rheumatoid arthritis. Rates of malignancies, MACEs, VTEs, and deaths were comparable among patients receiving upadacitinib and adalimumab. No new safety risks emerged with longer-term exposure to upadacitinib.Trial Registration NumbersSELECT-PsA 1: NCT03104400; SELECT-PsA 2: NCT03104374.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40744-021-00410-z.

Evaluation of Cardioprotective action of Suvarna gairik (Redochre) in Indian Cobra Envenomation, Aluminium Phosphide Poisoning and Doxorubicin Cardiotoxicity in Albino Rats- A Protocol

Background: Poisoning is major health issue all over the world. Poisoning is one of basic causes for Out Hospital cardiac arrest (OHCA). P-OHCA (Poison induced Out Hospital cardiac arrest) can be prevented by immediate primary management. The agent for poisoning is unknown in most cases, which leads to difficulty deciding the emergency antidote. In Ayurveda Hridyavaranchikitsa (Cardio protection) is one of the treatment modalities mentioned in all types of poisoning as first aid treatment. Suvarna Gairik (Red ochre) is one of drugs mentioned for the cardioprotection. Snake bite and organophosphate poisoning are the threats to life in India. Doxorubicin is commonly used drug for Chemotherapy in malignancies, and its major side effect is cardiotoxicity. Hence these poisonings are included in study.
 Aim and Objective: Evaluation of cardioprotective activity of Suvarna Gairik (Red ochre) in cardiac biomarker like Lactate dehydrogenase, Creatinine phosphokinase, Alkaline transferase, Cardiac Troponins and Survival Time in Indian Cobra Envenomation, Aluminium phosphide poisoning and Doxorubicin cardiotoxicity in Albino Rats.
 Methodology: Animal study is designed. 56 wistar rats will be divided in 7 groups as Vehicle Control Group, Disease control Group -1 Indian Cobra envenomation, Disease control Group -2Aluminium Phosphide poisoning, Disease control Group -3 Inj. Doxorubicin induced cardiotoxicity, Test Group -1 Indian Cobra Envenomation and Suvarna gairik Test Group -2 Aluminium Phosphide poisoning and Suvarna gairik Test control Group 3- Inj. Doxorubicin cardiotoxicity and Suvarna gairik.
 Results: Outcome will be assessed in between groups and among groups.
 Conclusion: Suvarna Gairik (Red ochre) may show statistical significant cardioprotective activity.

The effect of tourniquet on early postoperative quadriceps muscle wasting in ACL arthroscopic surgery

Background: The main goals of anterior cruciate ligament (ACL) reconstruction and rehabilitation are to reestablish knee function. Quadriceps weakness is one of the most important complications associated with ACL injury and represents a major rehabilitation challenge. This study is designed to test the early effect of tourniquet on muscle wasting and to differentiate weather it is because muscle disuse or injury. Methods: Twenty six male patients who submit to arthroscopic ACL reconstruction were randomly assigned to the use of an inflated (group T, n _ 13) or deflated (group NT, n _ 13) tourniquet. Patients with preoperative quadriceps wasting or abnormal electro conductive studies were excluded. The primary measures were thigh girth preoperatively and after two weeks, serum creatinine phosphokinase (CPK) preoperatively and one day postoperatively and electro conductive studies preoperatively and 1 month postoperatively. Results: Patients' mean age was comparable in both groups. There was a significant difference between T and NT groups in term of thigh girth, CPK and electro conductive studies. Mean thigh girth in T group was 2.6 ± 0.5 while in NT group 1.4 ± 0.5. Mean CPK in T group was 813 ± 149 while in NT group 520 ± 203. Mean femoral latency was 1.85 ± 0.4 in T group and 1 ± 0 in NT group; mean femoral conduction velocity was 1.77 ± 0.4 in T group and 1 ± 0 in NT group; mean muscle denervation was 1.92 ± 0.3 in T group and 1.54 ± 0.5 in NT group; mean motor unit number estimation was 1.9 ± 0.3 in T group and 1.5 ± 0.5 in NT group. Conclusion: This comparative study show that tourniquet play a significant role in direct muscle injury proved by measurement of postoperative CPK and thigh girth in T group comparing it with NT group.

Assessment of haematological and biochemical alterations in recumbent buffaloes

ABSTRACT The present study was undertaken on adult recumbent buffaloes (n = 63), which were clustered into six groups based on the history and tentative diagnosis viz., infectious, metabolic, traumatic, abdominal dysfunction, intoxication, and musculoskeletal and nervine. An additional group of 10 adult healthy control buffaloes was also included in the study. The blood, serum, and faecal samples were collected on zero day to perform haematological, blood smear, serum biochemical, and faecal examination, respectively. Also, the similar samples were collected on 5 days post treatment (DPT) in recovered and control animals. Genomic DNA from individual blood samples was isolated and subjected to conventional polymerase chain reaction (PCR) and quantitative PCR for exploring Trypanosoma evansi and Bovine Herpes Virus-1 infections, respectively. The detailed history of recumbent buffaloes revealed the mean age as 5.53 ± 0.34 years and duration of recumbency as 2.61 ± 0.38 days. Younger animals (3.92 ± 0.31 years) having ~14 hours of recumbency period showed recovery and good prognosis. On comparison of serum biochemical parameters of recovered and non-recovered recumbent animals, Aspartate Aminotransferase (AST), creatinine phosphokinase, phosphorus, sodium, and chloride showed significant difference between them (p < 0.05); thus, indicating their suitability for being prognostic indicators. Out of 63 recumbent animals, 10 (15.87%) showed recovery from recumbency after 5 DPT. The present study recognized the alterations in haemato-biochemical parameters in recumbent buffaloes for the first time.

Development of Rhabdomyolysis in the Long-term Period of Previous New Coronavirus Infection COVID-19 (Clinical Case Report)

Relevance. Rhabdomyolysis is one of the complications of the new coronavirus infection COVID-19, which may cause acute kidney injury (AKI). The reason for the development of rhabdomyolysis in our observation in a patient after suffering COVID-19 in the long-term period was an increased muscle load.Aim of study. Presentation of a case of rhabdomyolysis with AKI in a patient after COVID-19 in the long-term period.Material and methods. In clinical observation, a 25-year-old patient L. is presented, who was being treated in the Department for the Treatment of Acute Endotoxicosis of the N.V. Sklifosovsky Research Institute for Emergency Medicine. In 2020, he developed COVID-19, complicated by rhabdomyolysis and AKI in the long term period.Results. Examination revealed an increase in creatinine phosphokinase (CPK) — 106,000.0 U/L, alanine aminotransferase (ALT) — 553.0 U/L, aspartate aminotransferase (AST) — 1582.0 U/L, lactate dehydrogenase (LDH) — 2809.0 U/L, levels of serum creatinine 164 μmol/L and myoglobin — 201 ng/ml. Virological research: IgM — 0.27 units per ml; IgG — 7.28 units per ml. 3 Three-phase scintigraphy with 99mTc-pyrfotech revealed signs of necrotic changes in the muscles of the upper half of the back, muscles of the chest (mainly on the right), muscles of the shoulder and upper half of the forearm on both sides. Kidneys: decreased perfusion of the right kidney (relative to the left), moderate slowdown of urodynamics at the level of the calyx-pelvis complex on both sides.Conclusions. The reason for the development of rhabdomyolysis in the long-term period in the patient after suffering from COVID-19 was an increased muscle load. Targeted research and medical history can help identify signs of rhabdomyolysis. The use of the radionuclide diagnostic method makes it possible to identify areas of soft tissue damage with a one-step assessment of renal function in rhabdomyolysis in the acute period of the disease, as well as to evaluate the effectiveness of treatment with dynamic observation. When rhabdomyolysis is confirmed, it is necessary to carry out detoxification and infusion therapy, to monitor renal function in order to detect acute kidney injury, and in case of deterioration of renal function and intoxication, renal replacement therapy is indicated.

Should Posterior Midline Structures Be Preserved in Decompression Surgery for Lumbar Spinal Stenosis?: A Systematic Review and Meta-analysis.

This was a systematic review and meta-analysis study. The purpose of this study is to evaluate the available evidence on the preservation of posterior midline structures in decompression surgery for lumbar spinal stenosis (LSS). The gold-standard treatment for LSS refractory to conservative management is facet-preserving laminectomy. The question remains whether the midline structures should be preserved in decompression surgery for LSS. We performed a systematic review of the Medline, PubMed, Embase, and Cochrane databases in search of published reports comparing midline structure preservation (MSP) and conventional laminectomy (CL) for LSS. The population was divided into 2 groups: (1) MSP group (intervention) and (2) CL group (control). The various outcome parameters including blood loss, operation time, hospital stay, back and leg pain, functional scores including Oswestry Disability Index (ODI) score, Japanese Orthopedic Association score, and 36-Item Short Form Survey (SF-36) scores, satisfaction, and instability rates were analyzed. Data were extracted and aggregated for meta-analysis. Of the published reports, 16 met our inclusion criteria with an aggregated 540 in the intervention and 538 in the control groups, respectively. The aggregated data demonstrated patients undergoing MSP had significantly decreased back pain Visual Analog Scale compared with CL, regardless of time after surgery ( P =0.007). The MSP group also showed a significantly lower Oswestry Disability Index score and SF-36 Mental Component Summary score ( P =0.005 and 0.03, respectively) and longer 6-month walking distance ( P &lt;0.00001). The patient satisfaction rate was significantly higher in the MSP group ( P =0.02), and the instability rate was significantly lower in the MSP group compared with the CL group ( P &lt;0.0001). At 3 days after surgery, MSP significantly decreased the level of creatinine phosphokinase ( P &lt;0.00001). Regarding intraoperative blood loss, hospital stay, leg pain Visual Analog Scale score, Japanese Orthopedic Association score, and SF-36 Physical Component Summary score, there were no significant differences between the 2 groups. However, MSP showed significantly higher operation time ( P =0.04). We concluded despite heterogenous and limited data, this study suggests that preservation of midline structure leads to less severe back pain, better functional recovery, and satisfaction rate. Meanwhile, it decreases creatinine phosphokinase level and instability rate. Level III-therapeutic.

Cardiac Diagnostic Feature and Demographic Identification (CDF-DI): An IoT Enabled Healthcare Framework Using Machine Learning.

The incidence of cardiovascular diseases and cardiovascular burden (the number of deaths) are continuously rising worldwide. Heart disease leads to heart failure (HF) in affected patients. Therefore any additional aid to current medical support systems is crucial for the clinician to forecast the survival status for these patients. The collaborative use of machine learning and IoT devices has become very important in today’s intelligent healthcare systems. This paper presents a Public Key Infrastructure (PKI) secured IoT enabled framework entitled Cardiac Diagnostic Feature and Demographic Identification (CDF-DI) systems with significant Models that recognize several Cardiac disease features related to HF. To achieve this goal, we used statistical and machine learning techniques to analyze the Cardiac secondary dataset. The Elevated Serum Creatinine (SC) levels and Serum Sodium (SS) could cause renal problems and are well established in HF patients. The Mann Whitney U test found that SC and SS levels affected the survival status of patients (p < 0.05). Anemia, diabetes, and BP features had no significant impact on the SS and SC level in the patient (p > 0.05). The Cox regression model also found a significant association of age group with the survival status using follow-up months. Furthermore, the present study also proposed important features of Cardiac disease that identified the patient’s survival status, age group, and gender. The most prominent algorithm was the Random Forest (RF) suggesting five key features to determine the survival status of the patient with an accuracy of 96%: Follow-up months, SC, Ejection Fraction (EF), Creatinine Phosphokinase (CPK), and platelets. Additionally, the RF selected five prominent features (smoking habits, CPK, platelets, follow-up month, and SC) in recognition of gender with an accuracy of 94%. Moreover, the five vital features such as CPK, SC, follow-up month, platelets, and EF were found to be significant predictors for the patient’s age group with an accuracy of 96%. The Kaplan Meier plot revealed that mortality was high in the extremely old age group ( (1) = 8.565). The recommended features have possible effects on clinical practice and would be supportive aid to the existing medical support system to identify the possibility of the survival status of the heart patient. The doctor should primarily concentrate on the follow-up month, SC, EF, CPK, and platelet count for the patient’s survival in the situation.

TPE OR NOT TPE: USING THERAPEUTIC PLASMA EXCHANGE IN SEVERE RHABDOMYOLYSIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Rhabdomyolysis is a syndrome caused by damage to skeletal muscle and the release of its breakdown products into the circulation. It can be asymptomatic or progress to acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Therapeutic plasma exchange (TPE) also known as plasmapheresis has been reported as a treatment option but data is limited to a handful of case reports. [1,2] We report our institutional experience using TPE for rhabdomyolysis in 10 critically ill patients admitted to our ICU during 2012-2020. CASE PRESENTATION: The patient age range was from 23 - 63 years (mean 41.4 years) and predominantly male (n=8). The most common etiologies were traumatic (n=4), amphetamine-induced (n=2), and acute limb ischemia, heat-stroke, electrocution, sepsis, and cardiogenic shock. Six patients had no major medical comorbidities, while others had concomitant COPD, heart failure, atrial fibrillation with mesenteric ischemia, and traumatic subdural hemorrhage. Initial creatinine (Cr) ranged from 1.9 to 8 mg/dl (mean 4.0), creatinine phosphokinase (CPK) from 6,000-100,000 U/L, and myoglobin from 5000 to >20,000 ng/ml. All patients had acute renal failure and eight of them had at least one other organ dysfunction such as respiratory failure (n=7), shock (n=6), liver injury (n=1), or encephalopathy (n=2). SOFA scores ranged from 3-18 (mean 7.85). All patients required continuous veno-venous hemofiltration due to renal impairment. TPE was started within 48 hours of diagnosis. PRISMAX machines with TPE2000 filters were used to perform TPE via membrane plasma separation. Either 5% albumin or fresh frozen plasma were exchanged at a filtration fraction of 25%. Patients underwent 1-3 TPE sessions (mean 1.4). A decrease in myoglobin, CPK, and Cr was seen post-TPE. Six patients had resolution of condition with successful discharge from ICU. Two patients deceased secondary to multi-organ failure and two were transitioned to comfort care due to concomitant neurotrauma and poor prognosis. Length of ICU stay ranged from 3-14 days (mean 7.5). Among survivors, only one patient required renal replacement therapy (RRT) upon hospital discharge. All patients had complete resolution of kidney dysfunction at a 3-month follow-up. No complications due to TPE were seen. DISCUSSION: There are no RCTs evaluating optimal treatments for rhabdomyolysis, however, case series using TPE in severe rhabdomyolysis have reported favorable outcomes. Our case series shows similar findings and suggests that TPE was effective in clearing circulating myoglobin as well as potentially other cytokines which are thought to propagate the disease process [3]. CONCLUSIONS: TPE can be safely and effectively used to treat severe rhabdomyolysis with multiorgan dysfunction. Further studies are required to elucidate its exact role in preventing long-term kidney dysfunction REFERENCE #1: Swaroop R, Zabaneh R, Parimoo N. Plasmapheresis in a patient with rhabdomyolysis: a case report. Cases J. 2009;2:8138. Published 2009 Aug 12. doi:10.4076/1757-1626-2-8138 REFERENCE #2: Petejova N, Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care. 2014;18(3):224. Published 2014 May 28. doi:10.1186/cc13897 REFERENCE #3: Ronco C. Extracorporeal therapies in acute rhabdomyolysis and myoglobin clearance. Crit Care. 2005;9(2):141-142. doi:10.1186/cc3055 DISCLOSURES: No relevant relationships by Paul Bhamrah, source=Web Response No relevant relationships by Sukhmani Boparai, source=Web Response Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, source=Web Response, value=Consulting fee No relevant relationships by Cesar Davila-Chapa, source=Web Response No relevant relationships by Rajkamal Hansra, source=Web Response No relevant relationships by Prathik Krishnan, source=Web Response

SEVERE MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT WITH MYOCARDITIS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: There have been increasing reports of a rare hyperinflammatory syndrome seen in children following Coronavirus disease 2019 (COVID-19) with shared features of Kawasaki's Disease (KD). More recently, cases involving adolescents and young adults are emerging [1]. We present a case of severe multi-system inflammatory syndrome with myocarditis in a young adult. CASE PRESENTATION: A 20-year-old male with beta-thalassemia trait and a family history of Sjogren disease presented for screening after contact with a friend who tested positive for COVID-19. PCR testing confirmed COVID-19. He was asymptomatic at that time and was advised to quarantine at home.Five weeks later, he presented with a high-grade fever of 104 F, myalgias, difficulty breathing, chest pain, palpitations, hematuria, and hematochezia. Vital signs showed tachycardia (127 bpm) and hypotension (90/53 mmHg). Chest X-ray showed no infiltrates. Electrocardiogram (EKG) showed no ST abnormalities. Nasopharyngeal PCR was negative for COVID-19. Labs showed elevated C-reactive protein (CRP), creatinine phosphokinase (CPK), and lactate (8.0 mmol/L). Troponin T was elevated to 1.5 ng/L, and high sensitivity troponin was 12759 ng/L. Sequential Organ Failure Assessment (SOFA) score was 9. He was admitted to the intensive care unit (ICU) for cardiogenic vs distributive shock. Echocardiogram revealed new-onset reduced ejection fraction (EF) at 20%, with no wall motion abnormalities. He was anuric with rhabdomyolysis and acute tubular necrosis. He was treated with hemodialysis, intravenous N-acetylcysteine protocol, inotropic support, three doses of intravenous immunoglobulins (IVIG), corticosteroids, and aspirin. Serial blood cultures were negative. He had a high serum titer of COVID-19 antibody. Patient slowly improved following IVIG treatment and supportive care, with decreasing SOFA score. He was weaned off pressors and dialysis. Repeat echocardiogram showed recovered EF at 45%, and inflammatory markers improved to normal. After a 3-week hospital course, patient was near baseline with post-ICU deconditioning. DISCUSSION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is a rare post-infectious sequela of COVID-19 with shared features of KD. Proposed mechanisms include direct hypoxic, ischemic injury, and post-viral immune-mediated vasculitis. Patients usually have limited respiratory involvement, evidence of recent COVID-19, and high antibody titers, which supports a post-infectious, immune-mediated etiology. Myocarditis is more common compared with Kawasaki disease, and both can have coronary artery aneurysms. Limited data from case series show good outcomes with IVIG, corticosteroids, and aspirin [2]. CONCLUSIONS: MIS is a rare extrapulmonary complication of COVID-19 with a wide spectrum of presentation. Initially described in children, more cases are emerging in young adults. A multidisciplinary approach is essential in severe cases. REFERENCE #1: Hékimian G, Kerneis M, Zeitouni M, et al. Coronavirus Disease 2019 Acute Myocarditis and Multisystem Inflammatory Syndrome in Adult Intensive and Cardiac Care Units. Chest. 2021;159(2):657-662. doi:10.1016 REFERENCE #2: Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, et al. California MIS-C Response Team. COVID-19-Associated Multisystem Inflammatory Syndrome in Childre, March-July 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1074-1080. doi: 10.15585 DISCLOSURES: No relevant relationships by Mateus Fernandes, source=Web Response No relevant relationships by Ifediba Nwachukwu, source=Web Response

Mechanism of antibacterial effect for different venoms (Naja haje, Cerastes cerastes, Apis mellifera) on Staphylococcus aureus

Abstract The overuse and misuse of antibiotic without going to doctor leading to antibiotic resistant strains that represent a serious problem in the field of health protection, Staphylococcus aureus (S. aureus) remains one of the main causes for hospital infections specially in the intensive care unit (ICU), so that many researches directed to natural products as alternative antibiotic drug, nowadays special attention towards venoms as (elapids, viprides, honey bee venom, etc….) which contain molecules with antibacterial properties such as phospholipase A2 (PLA2), L-amino acids (LAAO) and melittin. The present study aimed to evaluate in vitro and in vivo antibacterial effect of three different venoms the Egyptian Cobra (Naja haje), the horned viper (Cerastes cerastes) and honey bee (Apis mellifera) on S. aureus. There were tested in vitro by Minimum inhibitory concentration (MIC) test and disc diffusion method. In vivo evaluation was performed by infecting groups of mice by S. aureus, then treated with these three venoms and standard antibiotic. The hematological studied showed that effect on Hb and RBCs not all groups like others compared to control. Biochemical analysis of mice sera, liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and kidney function (urea and creatinine) as well as cardiac enzyme creatinine phosphokinase (CPK) showed that all treated and untreated groups in biochemical studies recorded a significant increase in all liver, kidney and cardiac functions. Histological examination illustrated that liver and kidney tissue in untreated group with inflammatory cells infiltration, degree of inflammation decrease in both N. haje and C. cerastes groups, while A. mellifera and antibiotic groups approximately normal in both mice liver and kidney.

Crotalaria spectabilis poisoning in a horse

Plant poisoning is an important cause of death in horses and cattle in Brazil. Crotalaria sp. has stood out in this scenario due to its toxic potential caused by monocrotaline, a pyrrolizidine alkaloid found throughout the plant, mainly in seeds. Here is reported a case of Crotalaria spectabilis poisoning a horse. A horse consumed oats contaminated with Crotalaria spectabilis seed and presented clinical signs of toxicosis characterized by jaundice, progressive weight loss, hemoglobinuria, subcutaneous edema in the pectoral region and neurological symptoms typical of hepatic encephalopathy. In the serum evaluation, there was an increase in the activity of the enzymes alkaline phosphatase (ALP), gamma-glutamyl transferase (GGT) and aspartate transaminase (AST), urea, creatinine and creatine phosphokinase (CPK). At necropsy, the main macroscopic findings were opaque and congested liver with capsular irregularity and accentuated the lobular pattern, trachea with foamy and pinkish fluid and congested and edematous pulmonary lobes. The main histopathological findings were hepatic fibrosis, periportal ductal hyperplasia, centrilobular necrosis, megalocytosis and binucleated hepatocytes. The brain parenchyma showed perivascular edema and Alzheimer type II astrocytes. Crotalaria sp. is among the main plants that cause acute or chronic mortality after exposure to the toxic compound in horses and farm animals.

Post-coronavirus disease 2019 children in Sarajevo-Lessons learnt?

Introduction: A new disease coronavirus disease 2019 (COVID-19) is with insufficiently known epidemiological characteristics and spectrum of clinical expression in childhood. Children have a lower incidence of this disease with a predominance of mild forms but severe clinical forms, such as among others, acute respiratory distress syndrome, and multisystem inflammatory syndrome may occur, according to current findings. In children with atypical symptomatology and positive or suspicious epidemiological survey, practitioners should consider the possibility of COVID-19.Methods: This study formed the group of 70 children previously healthy or with no pre-existing heart disease from Sarajevo with positive post-COVID history. Following the history of disease and epidemiological data, establishing the 1st day of disease or contact, a detailed cardiovascular examination was performed, including parameters of body weight, height, oxygen saturation, pulse, blood pressure, 12 leads electrocardiogram (ECG) done on Schiller machine, values of polymerase chain reaction (PCR), or serological test on corona: Immunoglobulin (Ig) G and IgM. Echocardiographic examination was done using M, B mode, color, continuous wave, and pulse wave Doppler in standard views. Laboratory blood tests included: Full blood count, creatinine phosphokinase myofibril, creatinine phosphokinase, lactate dehydrogenase; liver enzymes, D dimer, C reactive protein, and urine.Results: Majority of children (64.3%) were asymptomatic. ECG was normal in relation to patients’ age except in eight patients (intermittent palpitations on exertion) who had short PR interval 0.120–0.140 ms, with no delta wave, with heart rate within the normal range according to age, so 24 h ECG Holter was performed without any significant arrhythmias, incomplete right branch block has been documented in 12%, monofocal ventricular ectopic extrasistoly in 15%. Mean IgG, as a marker of infection, showed a statistical significance when compared between age Groups I and II (&lt;5) and older groups: III, IV, and V (&gt;5) (p &lt; 0.05; p = 0.043). PCR test was negative in 9 (70 children), although they showed symptoms, COVID-19 infection clinical data, and positive laboratory findings. Echocardiogram was normal in all patients with normal ejection fraction of the left ventricle.Conclusion: The possibility of COVID-19 in children with atypical symptomatology and positive or suspicious epidemiological survey should be in the focus of every pediatrician at primary care institutions nowadays. Cardiovascular assessment should always be an option in post-COVID patients. Immunological assessment is necessary in post-COVID patients in order to gain a further understanding of PTS status. With more serological testing for severe acute respiratory syndrome coronavirus 2 physicians would be able to make a diagnosis of COVID-19 timely and more accurately, as well as to evaluate the role of asymptomatic children in disease transmission and to assess the importance of protective antibodies and the distribution of COVID-19.

Should Isotretinoin be Stopped Prior to Surgery?

Should Isotretinoin be Stopped Prior to Surgery?

Https://promedsci.org/articles/Propofol%20as%20a%20Rare%20Cause%20of%20Serotonin%20Syndrome

Serotonin is a hormone that has wide-ranging effects on the body including stabilization of mood, feelings of wellbeing, and happiness. Serotonin syndrome was first described in the early 1960s in animals. This syndrome was first fully described in humans by Sternbach in a review of 38 case reports. In this study, it was found that nearly all reported cases were found in patients taking a combination of antidepressants and other agents [1]1 Serotonin syndrome is a disease that is easily missed as there are no defining features in most cases. Symptoms such as confusion and tremors have a gamut of potential causes. Laboratory tests are non-diagnostic with possible changes including an increase in white blood count, creatinine phosphokinase, and decrease in bicarbonate levels. Here we present a case of Serotonin syndrome that was caused by Propofol use in which led to the patient presenting with respiratory arrest. The patient was treated appropriately and was discharged home in good health.

Clinico-hematological, patho-anatomical and molecular based investigation of blackleg disease in Cholistani cattle

Clostridium chauvoei, causing myonecrosis in livestock animals, lives in the feces, surface water and soil. The blackleg due to C. chauvoei is very common in dairy animals. Still, no report is available about the pathophysiology of disease in Cholistani cattle kept under tropical and desert conditions of Cholistan, Pakistan. Therefore, in this study, we report for the first time the pathophysiology of a visceral form of blackleg infection in indigenous cholistani cattle breed reared in desert conditions of Cholistan. Clinically morbid animals exhibited different signs of infection including fever, crepitation sounds, gaseous swelling and edematous lesions. Blood was collected for hematological and serum biochemical investigation. Hematological examination indicated a significant increased erythrocyte sedimentation rate, lower red blood cells, hematocrit, and total white blood cell count. Results on serum biochemistry showed significantly (p<0.02) increased creatine kinase levels, creatinine, urea, alanine aminotransferase, aspartate aminotransferase, alkaline phosphates, creatinine phosphokinase and lactate dehydrogenase in infected cattle. At necropsy level, light pink color fluid under swelling areas of skin, gas bubbles, dark to black in color of affected muscles and crepitation sounds at palpation were observed. Necropsy showed marked myocarditis, petechial hemorrhages, consolidation and severe pulmonary edema. Spleen showed petechial hemorrhages and congestion. Histological analysis of muscular tissues indicated severe inflammatory reaction comprising of cellular infiltration, marked edema, necrosis and disruption of myofibrils. PCR confirmed the presence of C. chauvoei in muscles, heart and exudates of the lungs. This is the first report on molecular detection of Clostridium chauvoei from a visceral form of Blackleg disease in cholistani breed of cattle naturally infected in the Cholistan desert of Punjab, Pakistan.

NEUROLEPTIC MALIGNANT SYNDROME IN PATIENTS WITH SCHIZOPHRENIA

Introduction: Neuroleptic Malignant Syndrome (NMS) is a rare and life treathening idiosyncratic reaction that can be caused by neuroleptic drugs with manifestation of fever, muscular rigidity, changes in mental status and autonomical dysfunction. NMS can happen soon after neuroleptic drugs initiation or after dosage increase. Ninety percent of cases can happen within 10 days and usually progress over 24-72 hours. Nevertheless, NMS can happen after years of therapy, therefore, antipsychotic administration requires a creatinine phosphokinase (CPK) examination. Elevated CPK level is a sign of rhabdomyolisis, secondary to muscular rigidity, caused by dopamine receptor blockage in the corpus striatum and nigrostriatal pathway. Establishing the diagnosis of NMS is based on The Diagnostic and Manual of Mental Disorder, fourth edition (DSM-IV) and Levenson’s clinical criteria. Case: A 27-year-old female presented with complaints of fever. History of schizophrenia for 12 years. Physical examination showed temperature 37.6°C; catatonic (+) ; muscular rigidity (+) ; blood pressure 130/90 mmHg ; pulse rate 118x/minute ; GCS E3 V1 M5. Hematological examination results: WBC 11x103/uL; and Plts 131x103/uL. Chemical chemistry examination result : AST 294 IU/L ; ALT 183 IU/L ; LDH 447 ; BUN 28 mg/dL ; serum creatinine 2.01 mg/dL ; hematuria ; proteinuria ; CPK 1,183.1 U/L. Conclusion: A schizophrenia patient on initiation, when increasing the dosage needs to be monitored with CPK to prevent the risk of neuroleptic malignant syndrome.

ClusterMix K-Prototypes Algorithm to Capture Variable Characteristics of Patient Mortality With Heart Failure

Cardiovascular Disease (CVD) is one of the leading causes of many death worldwide, leading to heart failure incidence. The World Health Organization (WHO) says the number of people dying from cardiovascular disease from heart failure each year has an average of 17,9 million deaths each year, about 31 percent of the total deaths globally. Identify the mortality factors of heart failure patients that need to be formed, which reduces death due to heart failure. One of them is by using variable mortality due to heart failure by applying the k-prototypes algorithm. The clustering result is formed 2 clusters that are considered optimal based on the highest silhouette coefficient value of 0,5777. The results of the study were carried out as segmentation of patients with variable mortality of heart failure patients, which showed that cluster 1 is a cluster of patients who have a low risk of the chance of mortality due to heart failure and cluster 2 is a cluster of patients with a high risk of mortality due to heart failure. The segmentation is based on the average value of each variable of heart failure mortality factor in each cluster compared to normal conditions in serum creatine variables, ejection fraction, age, serum sodium, blood pressure, anemia, creatinine phosphokinase, platelets, smoking, gender, and diabetes.

BOS172738, a highly potent and selective RET inhibitor, for the treatment of RET-altered tumors including RET-fusion+ NSCLC and RET-mutant MTC: Phase 1 study results.

3008 Background: RET (REarranged during Transfection) gene alterations (mutations and fusions) leading to constitutive kinase activity are identified as drivers of disease progression in multiple tumor types, including non-small cell lung cancer (NSCLC) and medullary thyroid cancer (MTC). BOS172738 is an investigational, potent, selective oral RET kinase inhibitor. This next-generation inhibitor was designed with nanomolar potency against RET and &gt;300-fold selectivity against vascular endothelial growth factor receptor 2, to maximize the potential therapeutic window. Methods: NCT03780517 is a phase 1 study consisting of a dose-escalation and dose-expansion phase. During the escalation, 67 patients with RET-altered advanced solid tumors received once-daily oral doses of BOS172738 (10-150 mg). Intra-patient dose escalation was allowed as was over-accrual to dose levels deemed to be safe. Study endpoints were safety (CTCAE v. 4.03), tolerability and confirmed overall response rate (ORR; RECIST 1.1). The data cutoff was Dec. 11, 2020. Results: BOS172738 exhibited a favorable safety profile (n=67) for long-term administration with most treatment-emergent adverse events (TEAEs) classified as grade ≤2 and deemed unrelated to drug. The most common TEAEs were creatinine phosphokinase (CPK) increase (54%), dyspnea (34%), facial edema, aspartate aminotransferase elevation, anemia (25% each), neutropenia, diarrhea (22% each), fatigue (21%), and constipation (20%). BOS172738 was not associated with hypertension or significant hepatoxicity. BOS172738 demonstrated broad anti-tumor activity with an investigator-assessed ORR of 33% (n=18/54), a NSCLC ORR of 33% (n=10/30), MTC ORR of 44% (n=7/16, including 1 complete response) and one patient with RET fusion+ pancreatic cancer reported a partial response. Responders included patients with brain metastases with one patient whose brain lesion decreased by 43%. The median duration of response has not been reached. Many patients remain on study, including the longest of 659 days, at data cutoff. BOS172738 exhibited dose-dependent exposure (AUC, Cmax), rapid absorption (median Tmax 1 to 4.5 h), and an extended half-life (approximately 65 hours) maximizing target coverage. Conclusions: BOS172738 is a highly potent and selective RET inhibitor with a differentiated safety profile and clinical activity against RET-altered tumors, including patients with brain metastases. BOS172738 continues to be evaluated in patients with NSCLC, MTC, and in patients previously treated with other selective RET inhibitors. Clinical trial information: NCT03780517.

Brigatinib in Japanese patients with anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC): First results from the J-ALTA tyrosine kinase inhibitor (TKI)-naive expansion cohort.

9042 Background: Brigatinib is a next-generation ALK inhibitor with demonstrated activity against ALK mutations. We report primary analysis results with brigatinib in Japanese patients with ALK-positive NSCLC who have not previously been treated with an ALK TKI in the phase 2 J-ALTA study (NCT03410108). Methods: J-ALTA, a multi-cohort study, included a TKI-naive expansion cohort. Patients in the TKI-naive cohort received brigatinib 180 mg qd with 7-day lead-in at 90 mg. Primary endpoint was 12-month progression-free survival (PFS) as assessed by an independent-review committee (IRC). Secondary endpoints included confirmed objective response rate (ORR; IRC- and investigator-assessed); IRC-assessed PFS and duration of response (DoR); overall survival (OS); intracranial PFS (iPFS by IRC); and safety. Results: A total of 104 patients were enrolled in the whole study; of these, 32 patients had TKI-naive NSCLC (median age, 60.5 y; 94% had adenocarcinoma; 22% had baseline brain metastases; 25% received prior chemotherapy). As of September 29, 2020, median follow-up was 14.2 months and 27 patients remained on treatment. IRC-assessed 12-month PFS was 93% (90% CI, 79–98). Confirmed ORR was 97% (90% CI, 84–100) by IRC, with 2 complete responses and 29 partial responses. Median DoR as assessed by the IRC was not mature; median PFS, iPFS, and OS were not reached. In the TKI-naive cohort, treatment-emergent adverse events (TEAEs) were reported in all 32 patients (most common: increased creatine phosphokinase, 81%; hypertension, 59%; diarrhea, 47%). Grade ≥3 TEAEs were reported in 91% of patients in this cohort (most common: increased creatinine phosphokinase, 44%; hypertension, 34%; increased lipase, 19%) and 75% of all patients. Three cases (9.4%) of interstitial lung disease/pneumonitis were reported in the TKI-naive cohort; all were grade 1 and occurred after day 15 of brigatinib treatment. Dose discontinuations/interruptions/reductions due to AEs in the TKI-naive cohort were 0%/94%/66%, respectively, and in the total study population were 5%/72%/41%. AE frequency and profile were similar in the TKI-naive and overall cohorts. Conclusions: In the J-ALTA TKI-naive cohort, brigatinib demonstrated substantial efficacy and manageable safety in the Japanese patient population. Brigatinib remains one of the treatment options in Japanese patients. Clinical trial information: NCT03410108.