Talk:Rhabdomyolysis/Archive 1

Archive 1

Archive 2

The

The inclusion of MDMA/ecstasy as a chemical cause of rhabdomyolysis seems a bit misleading, as I am sure there are hundreds of other stimulant-type drugs that could theoretically cause the condition, but it doesn't seem to be supported by any cited references. I'd like to see that phrase either removed or supported with a scholarly citation. --Kat.reinhart 00:56, 24 April 2006 (UTC)

---

Nescio, you added some references but it is unclear which statement in the article they support (e.g. the study that compares CK levels). JFW | T@lk 23:44, 1 October 2005 (UTC)

ICD-10

Arcadian observed that there is no ICD-10 code for rhabdomyolysis. Various articles found through Google suggest that it should be T79.6 for traumatic and M68.2 ("specified muscle conditions") for non-traumatic. JFW | T@lk 22:22, 8 November 2005 (UTC)

hello

i was interested in this topic sicne i have had it recently but i saw that this is almost the same inforation that is on a real phabdomyolysis site on the internet wrote by medical people and its not verry hepful.

thank, Wiki brah 19:20, 23 December 2005 (UTC)

It's probably because medical people wrote this page as well. Perhaps I can clarify some things and improve the page as we go. JFW | T@lk 01:01, 26 December 2005 (UTC)

Confusion

This is without a doubt one of the worst written pages I have ever read. There is no consistent line of presentation from beginning to conclusion. The information is disassociative and scatter and individual contributions many time attached out of location. You're not trying to prove how smart you all are but explain an important topic to the non-cognitive to assist them in assessing someone's condition. For god's sake get it right or dump the entire page.Confused619 (talk) 16:24, 14 February 2011 (UTC)

{{sofixit}} JFW | T@lk 22:23, 14 February 2011 (UTC)

I don't think that the identified problem should be solved. Wikipedia is not a medical manual. I frankly don't care if this article does not help you figure out how to assess someone's medical state. If you've got a question about someone's medical state, you need to get that person to a licensed medical healthcare provider. See WP:MEDICAL. WhatamIdoing (talk) 19:41, 15 February 2011 (UTC)

MDMA as a cause

There is no evidence (cited or otherwise) that MDMA is a chemical cause of muscle breakdown. It is possible that (indirectly) induced hyperthermia could lead to physical muscle breakdown, but not chemical.

Stating that MDMA is a cause of severe muscle breakdown, potentially leading to renal failure, is simply negligent.

MDMA can cause neuroleptic malignant syndrome, in which marked rhabdomyolysis is well recognised. JFW | T@lk 21:43, 21 March 2007 (UTC)

The fact that MDMA can trigger rhabdomyolysis is now sourced in the "causes" section. I invite the original poster to search on the keywords "rhabdomyolysis" and "MDMA" at http://pubmed.gov/ if several dozen more publications are desired. WhatamIdoing (talk) 22:34, 9 January 2008 (UTC)

While MDMA can be linked as a cause, I believe that a notice stating that it is much more frequent if the user is suffering from hyperpyrexia, muscle rigidity, or hyper-reflexia, as stated in http://bja.oxfordjournals.org/cgi/content/full/96/6/678#SEC4 (cited on the main page as 14). In a regular person not suffering from any of those, the risk of Rhabdomyolysis is much lower. 207.35.14.167 (talk) 08:31, 8 February 2008 (UTC)

(1) I think you should read the Neuroleptic malignant syndrome article.

(2) MDMA directly causes the overheating, muscle rigidity, etc. You seem to believe that if you're already running a high fever (perhaps because you're sick), then the addition of MDMA might trigger rhabdo. This isn't what happens. Here's what actually happens: MDMA causes rhabdo by getting you overheated, overworking your muscles, and helping you get dehyrdated. Given this, your request basically boils down to saying that if you didn't get any complications from MDMA, then you didn't get any complications from MDMA. I think the average reader is able to figure that out.

I don't really see any way to expand the information on MDMA without giving it undue weight in the article. However, if you really want to include the information, I could certainly add a (fully cited, factually accurate) paragraph that explains in detail exactly how MDMA causes rhabdo. We could justify it as an example of the complexity of chemical interactions, or something like that. As a point of fact, it won't be possible in that paragraph to suggest that MDMA is benign, however, so if that's your POV, then you might prefer that such details remained on my list of "probably not important enough to include." WhatamIdoing (talk) 19:45, 8 February 2008 (UTC)

The LSD claim seems even more suspect. The source mentions only increased ATP demand and its source doesn't mention LSD at all, as it's a study pertaining specifically to phencyclidine. —Preceding unsigned comment added by 99.20.209.149 (talk) 07:09, 24 April 2011 (UTC)

On the note of LSD being included, the source indicates that any drug which causes delirium or agitation might be held responsible for rhabdomyolysis, though, it also lists paracetamol as being a narcotic, which in turn is a little suspect. 'Table 2' here seems to be mainly a primary source, and on a clearly contentious topic such as this, possibly best flagged as such. 81.106.34.124 (talk) 03:09, 21 January 2014 (UTC)

If LSD is listed in two major sources then whatever the mechanism it should be included here. Most of the "lists of causes" from the literature are based on case reports and small case series; that's the trouble with the medical literature sometimes. JFW | T@lk 06:49, 21 January 2014 (UTC)

Tasers and Stun Guns

Perhaps an additional statement regarding the use of tasers and stun guns should be added as a cause of Rhabdomyolysis. I see that "Electric Current" is included, but as a nurse, I have treated many psychiatric patients who were tasered by the police and who became ill with Rhabdomyolysis as a result - some seriously, requiring a stay in ICU before the primary, psychiatric condition could be treated.—Preceding unsigned comment added by 4.246.224.248 (talk • contribs)

Can you identify a publication that says stun guns are specifically involved? Even if none of your tasered patients were drunk, high, engaged in strenuous exercise, or otherwise already on the high-risk list, the threshold for inclusion in Wikipedia is its verifiability in an independent publication with a reputation fact-checking, not whether or not we believe it to be true. WhatamIdoing (talk) 22:43, 9 January 2008 (UTC)

It is true, as one might guess, and I've added it with an apporpriate citation.FelixFelix ^talk 10:28, 1 March 2008 (UTC)

Rhabdomyolysis and Lactose Poisoning

I was admiited to [NAME OF INSTITUTION REMOVED] on January 19th, 2007, after collapsing with Legionaires Disease and renal failure. Unfortunately, I am lactose-intolerant, but was force-fed a normal diet for the four weeks I was in a coma. I lost over 40kgs. On my discharge summary, it stated I was diagnosd with Rdabdomyolysis on admission. My contention is the lactose poisoning may have caused this, given my reactins were phusically similar to previous attacks of lactose poisoning. The discharge statement is false also because while I was losing weight and maintaining zero kidney function, the hospital staff informed a nurse from another department that there was no clue as to the cause of my muscle breakdown: which ocurred after my admission. Reference discharge summary [NAME OF INSTITUTION REMOVED] 21/03/2007; patient MRN [REMOVED] --Alarchdu (talk) 12:55, 27 November 2007 (UTC)

I'm affraid that unless your case is reported in the medical literature we cannot reproduce your account. Encyclopedias are meant to be verifiable and not contain original research.

If you think "lactose poisoning" caused rhabdomyolysis, I would recommend you discuss this with your own physician at the first instance, rather than trying to create a new diagnostic entity. Searching Pubmed (a database of all medical research since the 1950s) does not give any results, indicating that lactose intolerance is not a generally recognised cause of rhabdomyolysis.

It bears pointing out that lactose does not normally enter the bloodstream in lactose intolerance. Quite the opposite: it is not absorbed properly at all. It is therefore unlikely to directly affect muscle or kidney function. JFW | T@lk 06:34, 28 November 2007 (UTC)

Fever and antibiotics are known triggers for rhabdomyolysis. The simplest explanation for your rhabdomyolysis is your infection, not things that happened after you'd already developed all the signs of rhabdomyolysis (like the kidney failure that you say you had at the time of admission). If you still have concerns about this, there's really nothing like sitting down with your regular doc and all your test results to sort out whether or not your admission dx is correct. WhatamIdoing (talk) 19:35, 2 January 2008 (UTC)

When I typed my original comments (as alarchdu), I was still learning to type, hence the errors. I have come back to this three years later, by happenstance. It seems that time has not removed the blinkers from everybody. After three years of further medical literature research and innumerable discussions, it seems that my original contention is still valid. I can imagine why no reliable lactose intolerance experiments have been done. It would take a very brave (or very masochistic) lactose-intolerant person to willingly ingest about the 15 grams of lactose sugar in one hour needed to develop observable lactose poisoning symptoms. Thus it remains in the realm of theoretical medicine.

After about two hours these symptoms include feverish temperatures and copious sweating, dangerous hypertension, uncontrollable vomiting and dry retching, and debilitating diarrhoea. Smaller doses of lactose ingestion cause only antisocial gaseous effusions. Contrary to the comments made about my original statements, I never said that lactose intolerance was a cause of rhabdomyolysis. Rather it is the ingestion of lactose by the lactose intolerant, already suffering from a severe infection, that can cause and maintain rhabdomyolysis even when the original infection has been cured, since lactose ingestion will cause the mimicing of all the symptoms of an infection in the lactose intolerant. Neville J. Angove (talk) 11:38, 14 December 2010 (UTC)

Wikipedia is not a site for original research, and it is definitely not a medical research facility. Rhabdomyolysis associated with Legionnaires and renal failure is old news. No one has "blinkers on". There is simply no evidence in the medical literature to support the hypothesis. Wikipedia is not a crystal ball. This is a page for improving the article on the subject, not a forum for unethical (inducing rhabdomyolysis in human subjects) medical research proposals.Novangelis (talk) 15:40, 14 December 2010 (UTC)

Despite your claims of having researched the medical literature and held discussions you have not provided a satisfactory explanation why ingestion of an unabsorbed carbohydrate would increase the risk of rhabdomyolysis. As others have indicated, this is an encyclopedia and not a medical journal or patients' forum. I have now also removed the name of the hospital because it is obvious that you have a beef with the hospital that treated you, and this is not WikiLeaks for healthcare institutions. JFW | T@lk 20:55, 14 December 2010 (UTC)

I suppose that if the lactose caused diarrhea, it might have aggravated renal failure. NB that this would require the "force-feeding" to involve pumping food into the stomach; lactose intolerance only affects food physically in the gut, not nutrition through an IV.

However, the fact remains that Wikipedia reports what is in the published reliable sources, not what is claimed by a person who says that he believes that this is the cause of his complications. Wikipedia has significant experience with users telling outright lies, and while I happen to believe this person's sincerity, it's simply not enough. Any such statement absolutely must be backed up by a properly published, reliable source with a reputation for fact-checking.

Alarchdu, if you want this mentioned, the thing to do is to get someone to publish a case study. Unless and until we have that in hand, we can no more mention your belief in this article than we can mention my friend's belief that she developed cancer because she was insufficiently friendly. Wikipedia does not report personal experiences, full stop. WhatamIdoing (talk) 19:36, 15 February 2011 (UTC)

Collaboration

I'd be happy to help... but I don't know much about this topic or what the article's needs are. Can someone post a task list here, or a vision of what the article might look like at the end (beyond than "longer")? WhatamIdoing (talk) 22:55, 31 December 2007 (UTC)

The article does not presently conform to WP:MEDMOS. There are sections with non-standard headings, and there is no useful list of signs and symptoms - the first thing someone would look for.  Done

There is a substantial amount of content that is presently unsourced. Some of the sources below may assist, but they need to be footnoted rather than listed at the bottom.

There is no epidemiology (for which sources may be hard to find) or a section on prognosis.  Done

Compare this article with similar medical featured articles (pneumonia, prostate cancer). JFW | T@lk 14:54, 1 January 2008 (UTC)

We've made some progress. What's next? Is there a particular section that you'd like to have sourced or expanded? Should we re-invite WPMED folks to come take a look before the topic changes on Monday? WhatamIdoing (talk) 22:45, 13 January 2008 (UTC)

Moved from the article

The following sources were mentioned in the article:

• Dennis Ausiello; Goldman, Lee. Cecil Textbook of Medicine Single Volume e-dition -- Text with Continually Updated Online Reference. Philadelphia, PA: W.B. Saunders Company. ISBN 0721639011.{{cite book}}: CS1 maint: multiple names: authors list (link)
• Edward Benz; David Weatherall; David Warrell; Cox, Timothy J.; Firth, John B. Oxford Textbook of Medicine. Oxford [Oxfordshire]: Oxford University Press. ISBN 0198569785.{{cite book}}: CS1 maint: multiple names: authors list (link)
• Holt SG, Moore KP (2001). "Pathogenesis and treatment of renal dysfunction in rhabdomyolysis". Intensive care medicine. 27 (5): 803–11. PMID 11430535.
  Subsequent reply:
  • Korantzopoulos P, Galaris D, Papaioannides D (2002). "Pathogenesis and treatment of renal dysfunction in rhabdomyolysis". Intensive care medicine. 28 (8): 1185, author reply 1186. PMID 12400515.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Llach F, Felsenfeld AJ, Haussler MR (1981). "The pathophysiology of altered calcium metabolism in rhabdomyolysis-induced acute renal failure. Interactions of parathyroid hormone, 25-hydroxycholecalciferol, and 1,25-dihydroxycholecalciferol". N. Engl. J. Med. 305 (3): 117–23. PMID 6894630.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• de Meijer AR, Fikkers BG, de Keijzer MH, van Engelen BG, Drenth JP (2003). "Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey". Intensive care medicine. 29 (7): 1121–5. doi:10.1007/s00134-003-1800-5. PMID 12768237.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Baggaley, P. (1997). "Rhabdomyolysis". Retrieved 2007-10-14.

I have moved them here now, but they might be useful as sources once they can be footnoted. The personal webpage is interesting, but primarily as a source for further references. JFW | T@lk 14:54, 1 January 2008 (UTC)

Image

This article could really use an image to help the reader relate to what is being said. If anyone has an image that could be applied, please upload it to the Wikimedia Commons so we can place it on the article. Thanks. Cyclonenim (talk) 17:24, 2 January 2008 (UTC)

Do you have any ideas about what that image should communicate? My imagination has utterly failed me today. "Here's a person with rhabdomyolysis: note the swollen elbow" seems like it communicates only slightly more useful information than "Here's a picture of a hospital. Rhabdomyolysis is normally treated in hospitals." (If we're just looking for something to be decorative, then I suppose that even these pathetic ideas would be acceptable, but I suspect that you had a more serious goal in mind.) WhatamIdoing (talk) 19:25, 2 January 2008 (UTC)

I would not immediately object to an image of a collapsed building, as crush injury was the first well-recognised cause for rhabdomyolysis. But real illustrative images would be of the myoglobin molecule, the microscopic pathology of acute tubular necrosis, and perhaps a haemofiltration machine. JFW | T@lk 11:15, 6 January 2008 (UTC)

I've added a picture of myoglobin (swiped from the Myoglobinuria page). I found a pic of a hemodialysis machine on Wikipedia, but not a hemofiltration machine. WhatamIdoing (talk) 23:21, 9 January 2008 (UTC)

I've found a photo of a bombed-out building that I think illustrates the idea of a major disaster. I'm not entirely satisfied with the caption and would be happy to have anyone else improve it. WhatamIdoing (talk) 23:05, 13 January 2008 (UTC)

I don't see the image relevant to the article at all. Mykhal (talk) 19:52, 28 April 2009 (UTC)

Sources

At the moment we are citing some very basic science papers and a review from a Saudi low-impact journal. I don't think these are tremendously useful sources, and I think we should strive to build the article around comprehensive reviews in high-impact journals.

I've found the following:

• PMID 17338959 (Eur J Int Med, not very high impact but comprehensive)
• PMID 17909702 (Intern Emerg Med, again IF low)
• PMID 17079586 (Pediatrics, more informational on children but free fulltext)
• PMID 15774072 (Crit Care, comprehensive and free)
• PMID 10906171 (J Am Soc Nephrol, free but from the renal perspective - by the team that also wrote the last Lancet seminar on ARF)
• PMID 11898964 (Am Fam Physician, free, from the primary care perspective but usually very good)
• PMID 11430535 (Intensive Care Med, renal perspective)

I will read the Crit Care paper and possibly the JASN one to see which one would be most useful - probably both. JFW | T@lk 11:15, 6 January 2008 (UTC)

Given that the list of "causes" was largely unreferenced, I have replaced it entirely with a list based mainly on the Crit Care 2005. The list of drugs in that article was very long, often with no mention of the mechanism (apart from diuretics causing hypokalemia). I have therefore mentioned only the most important ones. PMID 15021204 is an article specifically on drug-induced RM in children. I'm not sure if we should reintroduce the PMID 17344731 (Ann Saudi Med) reference - it almost 10 years old in a low-impact journal. This is a list in the 2006 Pharmacy Times.

I'm reproducing the EBM Guidelines article reference here. JFW | T@lk 13:41, 6 January 2008 (UTC)

Statins

I don't think we can support statins as an agreed cause any longer (except perhaps in the specific named case, which I haven't looked up):

A matched-control observational study at Kaiser Permanente indicates that statin initiation did not appear to be associated with an increased risk for rhabdomyolysis, with all patients having a rate of rhabdomyolysis of about 0.2 per 1000 person-years. A review of randomized clinical trials agrees that there is no association.

Should we delete statins from the list? Does anyone know more about this than I do? (The first ref here might be useful for a new epidemiology section.) WhatamIdoing (talk) 21:57, 9 January 2008 (UTC)

I disagree. On statin we are citing a very carefully constructed observational study on the risk of myopathy and rhabdomyolysis. Every review I have looked at during the preparation of my contributions mentions statins prominently. That kind of consensus in the literature is not displaced by the papers you have linked. All we can do, if you insist, is citing both views in an NPOV manner: "Many studies [1],[2] but not all,[3] [4] show that statin use, especially together with fibrates, increases the risk of myopathy and rhabdomyolysis. JFW | T@lk 07:25, 10 January 2008 (UTC)

Since the sources I found are very new, I'm not at all surprised that their conclusions are not cited in older works. I'd be fine with listing all the sources, but right now the only source listed in the article is the Crit Care review, and it provides no actual data that statins (except cerivastatin) are associated with an increased rate of rhabdomyolysis. What's the PMID for the study you want to cite? WhatamIdoing (talk) 20:45, 10 January 2008 (UTC)

PMID 15572716. JFW | T@lk 22:04, 13 January 2008 (UTC)

Bicarbonatecruft

The article made it out as if bicarbonate infusion is the standard of care, and supports this largely with non-clinical research. In fact, the CritCare2005 paper makes it clear that there is not a lot of evidence that bicarbonate makes any difference on outcomes. I am moving the content here for consideration:

If the exacerbating cause includes overdose of skeletal muscle relaxants and/or tricyclic antidepressants, the treatment protocols include gastric decontamination. This procedure is fairly effective because the anticholinergic effects of tricyclics and cyclobenzaprine delay gastric emptying; and, therefore, it becomes possible to obtain tablet residues even after significant time elapse. Ventricular arrhythmias, QRS widening, or intraventricular conduction abnormalities should be treated with sodium bicarbonate 1 meq/kg IV bolus and repeated if arrhythmias persist. This should be followed by IV infusion of sodium bicarbonate to produce an arterial pH of 7.5; the mechanism of sodium bicarbonate's action in this role is unknown. However, sodium bicarbonate's beneficial effect on kidney function is known to be via the effects of alkalinisation both increasing the urinary solubility of myoglobin leading to its increased excretion and stabilizing ferryl myoglobin complex so preventing myoglobin-induced lipid peroxidation.

I also feel that we should not be using case reports where better studies (preferably reviews or trials) are available. JFW | T@lk 07:25, 10 January 2008 (UTC)

Vitamin D

About the calcium-phosphate-Vitamin D issue: Are you aware of any reports of exogenous Vitamin D supplementation? It seems (from the theoretical perspective) that it might interrupt that vicious cycle. WhatamIdoing (talk) 02:09, 27 January 2008 (UTC)

Vitamin D is only part of the problem. The hypocalcaemia is mainly due to the hyperphosphataemia, but PMID 6894630 showed low vitamin D levels. Treatment of the hypocalcaemia is associated with "overshoot" hypercalcaemia in the later stages. I am not aware of any studies showing a benefit of vitamin D in this setting. JFW | T@lk 02:38, 27 January 2008 (UTC)

On reflection, administering vitamin D will simply increase the amount of calcium available for precipitation with phosphate. It might be a bad idea. If the hypocalcaemia was causing arrhythmias or tetany I'd treat gently with some calcium gluconate. JFW | T@lk 15:42, 31 January 2008 (UTC)

Bywaters

PMID 2279155 is a fascinating historical account on how the doctors at the RPMS/Hammersmith discovered the mechanism of rhabdomyolysis. It turns out that many of their discoveries had already been made in Messina and during WWI, and that they rediscovered much of this; this was however without the benefit of their library facilities, because London was being bombed etc. When rereading the "pathophysiology" paragraph I cannot help but notice how much these guys discovered and how little has changed since then.

On an unrelated note, Bywaters makes the astonishing mention of Ludwig Wittgenstein assisting the team in Newcastle, specifically his skill in preparing lungs from autopsied patients for inspection! JFW | T@lk 21:58, 2 February 2008 (UTC)

GA review

General comments

• Prose still a bit abrupt and technical, try to reduce the number of parentheses.
  • Thanks for your copyedit. I will try to do some more; I don't think we can do away with the parentheses and at the same time explain all the jargon. JFW | T@lk 09:47, 24 February 2008 (UTC)

Specific comments

• "The absence of myoglobin in the urine does not rule out rhabdomyolysis, but its presence in the urgent setting may be indicative of impending kidney damage" - I don't know what "in the urgent setting" means.
  • The article explains elsewhere that myoglobin has a short half-life. JFW | T@lk 09:47, 24 February 2008 (UTC)
  •  Done - I've removed it because it is of no relevance to anyone. JFW | T@lk 16:01, 24 February 2008 (UTC)
• ATP is not a source of energy, it is an energy-transfer molecule.
  •  Done I have corrected this. JFW | T@lk 09:47, 24 February 2008 (UTC)
• Calcium increases reactive oxygen species? I've not heard that before, needs a reference.
  • This is from the Vanholder source. I will dig out the paper on which this premise was added. JFW | T@lk 09:47, 24 February 2008 (UTC)

I'll put this on hold for now, but its almost there. Tim Vickers (talk) 02:44, 24 February 2008 (UTC)

Vanholder base their mention of calcium-related free radical generation on PMID 8821813 - I have no access to that journal from home. doi:10.1007/BF00296670 seems to discuss this, and PMID 2876985 indicates that calcium simply potentiates free radical toxicity rather than being the prime suspect. JFW | T@lk 10:07, 24 February 2008 (UTC)

Looks to me like Ca2+ activates a phospholipase that damages the mitochondrion, which will cause ROS production. I've changed the article to say this for now but if the more specific refs contradict this feel free to change it back. This seemed off to me since calcium isn't a redox-active transition metal, so can't produce ROS directly. Anyway, looks good now, I'll list this as a GA. Congratulations everybody! Tim Vickers (talk) 17:03, 24 February 2008 (UTC)

Thanks Tim! JFW | T@lk 21:06, 24 February 2008 (UTC)

Remaining issues

Tim's GA review has prompted me to give the article another look. I have changed some references to higher-quality sources, tried to eliminate more technospeak and parentheses, and improved the "list of causes" by splitting the list of pharmacological causes.

Issues that remain as far as I am concerned:

• It would be nice to have a photomicrograph of myolysed muscle and/or necrosed tubules.

  Asked Emmanuelm, one of our pathologists. JFW | T@lk 13:04, 2 March 2008 (UTC)

• We should have a picture of a haemofiltration machine - I will try to acquire one at work. Alternatively, a nice picture of a bag of normal saline would be illustrative.

   Done Image of haemodialysis machine was added. JFW | T@lk 13:04, 2 March 2008 (UTC)

• There are two redlinks: International Society of Nephrology and Haff disease.

   Done JFW | T@lk 13:04, 2 March 2008 (UTC)

• There is still relatively little mentioned about prognosis. I have not found much information in my various sources. Lots of other secondary sources repeat the mantra that the prognosis of rhabdo depends on the cause.

  Had another search - most sources deal specifically with one particular cause (e.g. burns - PMID 18182927). I suspect this section may not be expanded. JFW | T@lk 13:04, 2 March 2008 (UTC)

Much of this is not crucial for GA, but would enhance the article and make it more likely to become a FA. JFW | T@lk 12:25, 24 February 2008 (UTC)

Changes

I trawled through today's changes, and I'm not sure about the removal of this sentence: "High potassium levels occur in traumatic rhabdomyolysis but not necessarily in other forms." Do we have a source to support this trauma-but-not-others claim? WhatamIdoing (talk) 19:02, 1 March 2008 (UTC)

I'd be surprised if you do find one-potassium would tend to be higher with more extensive rhabdo-but there's no reason that trauma per se would do so.FelixFelix ^talk 22:40, 1 March 2008 (UTC)

Yet this is what the sources mention. I would not remove content that has a good reference behind it unless you can provide good evidence that (1) the source is wrong, (2) the source has been superseded, (3) there are exceptions to a generalisation made by the source etc etc. JFW | T@lk 07:14, 2 March 2008 (UTC)

The rationale for the critical care review article stating that PD is less effective for Rhabdo is that it's not as effective at removing potassium efficiently-as you can see that is based on the one cited reference in the article (number 144); Nolph K, Ann Intern Med 1969, 71:317-336. [1]. The Chitalia article (2002) that I referenced essentially looks at modern tidal PD vs what they call continuous equilibrating peritoneal dialysis, what we would call CAPD-which is what they had back in 1969-and found it was much better at solute removal. My view was that making this differentiation in the article was unnecessarily technical and a bit spurious, hence my previous edit-which I still think is better. Of course PD is only used for acute renal failure, to my knowledge, in the third world anyway, and I'm not terribly surprised that a critical care review would be a bit ignorant on PD. But there you go.FelixFelix ^talk 08:31, 2 March 2008 (UTC)

Rhabdomyolysis and Crossfit

I learned about rhabdomyolysis from this article on the Crossfit phenomenon. This condition seems to be a big issue in the Crossfit community. They even have a mascot called Uncle Rhabdo — a vomiting clown.

The article needs to say more about exercise and rhabdomyolysis, since that seems to be the context in which most people will encounter it.--Isaac R (talk) 17:35, 23 March 2008 (UTC)

I'm afraid most people will encounter it under a pile of rubble. I think this is a repulsive reference and deserves as little attention as possible. JFW | T@lk 15:01, 15 May 2008 (UTC)

Rhabdomyolysis is a repulsive disease; does that mean we should remove this article? Content is chosen based on importance and relevence, not its inoffensiveness. Isaac R (talk) 15:44, 19 May 2008 (UTC)

I'm slow today, I just now got the "pile of rubble" reference. I think you'll find that the number of people caught up in fitness fads is comparable to the number of people injured in collapsing buildings. It may be harder to sympathize with fadists than with victims of earthquakes or wars, but that doesn't make their issues any less significant. Isaac R (talk) 16:27, 19 May 2008 (UTC)

Can you provide a reliable reference (ideally a scientific journal) that goes beyond the current statements in the article (which already mentions "extreme physical exercise"), and says that this is relatively common among exercise enthusiasts? The mere fact of them joking about it isn't enough, IMO. WhatamIdoing (talk) 19:34, 29 May 2008 (UTC)

I'm not describing an epidemic of Rhabdomyolysis, I'm talking about a cultural phenomenon amongst followers of a fitness fad. Awareness of the condition is documented in the article I pointed to; statistics are beside the point.¶There must be a lot of self-diagnosis of Rhabdomyolysis in the fitness community, most of it probably based on misinformation. I think it would be very useful if somebody with real medical expertise (not me!) were to look at the perceptions of this condition and contrast them with medical reality.Isaac R (talk) 16:03, 14 July 2008 (UTC)

...which is not a task for Wikipedia. Unless you can provide a source like WhatamIdoing suggested I'm really not sure if there is anything we can include. JFW | T@lk 18:08, 14 July 2008 (UTC)

Ice Climbing

J. Campbell's notes in the [2] thread suggested the Rhabdomyolysis link to me. This note is more or less analogous to the Crossfit note above, but substitute "Screaming Barfies" for "Uncle Rhabdo". In both cases, we have a community coming up with a black comedy term to describe a very common but extraordinarily painful shared experience. The barfies are a very common occurrence in ice climbing, and occasionally happen in other forms of cold weather climbing (I got them yesterday morning on my right side after using mechanical ascenders, right hand high, on a long fixed line). I've never heard of a case where symptoms did not go away after a few minutes (it's a bit like eating too much wasabi, only it lasts longer and is a whole lot less fun).

The same arguments against including Crossfit in this page will of course apply to ice climbing and the dreaded Screaming Barfies. However, I strongly suspect that J. Campbell is correct in his guess that the barfies are a mild form of rhabdo. If he is, then the assertion that rhabdo is a rare occurrence is then incorrect. --Eric H.66.193.41.200 (talk) 21:03, 5 December 2008 (UTC)

You've sent me to a thread on some discussion forum. It is not entirely clear what makes you think that this phenomenon is identical to rhabdomyolysis. For one thing, the symptoms of clinical rhabdomyolysis last much longer than the few minutes you are referring to. Just like the CrossFit clown, much of this seems speculation rather than established medical fact. Let me know if there are any reliable reports on the matter. JFW | T@lk 19:46, 6 December 2008 (UTC)

Diff?

Should Myoglobinemia redirect here? WhatamIdoing (talk) 21:59, 27 June 2008 (UTC)

 Done. The source was poor, too. JFW | T@lk 06:56, 29 June 2008 (UTC)

Grateful reader

I would like to note that I am very greatfull for this information. My son who is 21 suffered from Rhabdomyolysis not from exercise or under a heap of rubble, but from simply falling asleep on his arm while helping his uncle work on his rental property out of town. The property didn't have any furniture so they slept on the floor. My son woke up not being able to move his arm and had to be rushed to the hospital. 3 surgeries later and dialysis he is home trying to figure out how to lead a productive life without the use of his left arm. This happens more than one might think and under some bizarre circumstances. ACS76.122.144.187 (talk) 01:27, 14 July 2008 (UTC)

ACS, I'm sorry to hear your boy has had such a rough time and I hope things are a bit better. Hopefully the Wikipedia page was informative; let us know if anything seems incorrect or could be phrased in a more sensitive manner. JFW | T@lk 09:30, 14 July 2008 (UTC)

Caffeine

Two users recently added a reference to PMID 10592946. This is a single case report on rhabdomyolysis after drinking 15 litres of oolong tea; even the abstract suggests that the link between its caffeine content and rhabdomyolysis may have been confounded by the conincidental hyponatraemia. I cannot imagine this is sufficient, and the major reviews (Crit Care and JASN) both ignore the report. JFW | T@lk 07:27, 4 August 2008 (UTC)

PMID 2642675, also a case report, would possibly have been better, as pure caffeine was used. PMID 1749057 mentions caffeine in combination. These reports predate Crit Care and JASN, and the fact that they don't include caffeine in their lists of causes probably reflects the fact that the link is poorly established. JFW | T@lk 07:30, 4 August 2008 (UTC)

Case series

PMID 16267412 has a large case series (475) of rhabdomyolysis. Some potentially interesting data, but I can't see whether this has been quoted in the reviews or not. JFW | T@lk 21:32, 17 August 2008 (UTC)

Tying Up or Equine Exertional Rhabdomyolysis

This article needs to reference the article on "tying up," otherwise known as Equine Exertional Rhabdomyolysis. Veterinary medicine is a lot more familiar with the condition.Godofredo29 (talk) 19:30, 15 November 2008 (UTC)

You mean more familiar than human medicine? Perhaps this is a candidate for "see also", with a dedicated article somewhere else. JFW | T@lk 22:51, 15 November 2008 (UTC)

Accutane

An anonymous contributor added that Accutane, a retinoic acid derivative used in acne, could cause rhabdomyolysis. A quick Pubmed search here shows that there are three case reports on the subject, and a further small study that shows that elevated CK in people on Accutane is a benign phenomenon. Given that we have no secondary sources discussing this, I don't think there is much point in mentioning this in the article.

There are numerous case reports on "some substance" causing rhabdomyolysis. This is easy research (muscle pain + high CK + patient taking odd drug + patient gets better when drug gets stopped), and often there are significant problems with the quality of the research. We must stick with our main sources when listing chemical causes of rhabdomyolysis. JFW | T@lk 20:28, 31 December 2008 (UTC)

Rhabdomyolysis and Renal disease

It was suggested in the body of the text that liver failure is associated with rhabdomyolysis in around 25% of cases. This is supported by an article in 'critical care'. However, if you look at their source for that figure, it is a small study of patients with non-traumatic rhabdomyolysis (PMID: 2343880). Their definition of hepatic impairment included patients with only a high AST, ALT and LDH, all of which are released from damaged muscles and are not specific for liver disease in this condition. This fact often leads to rhabdomyolysis being confused with acute liver failure if a CK test is not performed particularly in non-traumatic cases where there may be only non-specific symptoms. I changed the text to reflect this fact. gearoidmm (talk) 22:52, 5 January 2009 (UTC)

Thanks for fixing that, it makes a lot more sense now. JFW | T@lk 23:45, 5 January 2009 (UTC)

NEJM review

Will need to pull this and update the article if needed: http://content.nejm.org/cgi/content/short/361/1/62 JFW | T@lk 10:27, 2 July 2009 (UTC)

Here are a few other recent (post-2006, as there are few articles past that year) reviews. I'm no doctor though, so I'm not clear how ultimately useful they are.

Elsayed EF, Reilly RF (2009). "Rhabdomyolysis: a review, with emphasis on the pediatric population". Pediatr. Nephrol. 25 (1): 7–18. doi:10.1007/s00467-009-1223-9. PMID 19529963. {{cite journal}}: Unknown parameter |month= ignored (help)

Bagley WH, Yang H, Shah KH (2007). "Rhabdomyolysis". Intern Emerg Med. 2 (3): 210–8. doi:10.1007/s11739-007-0060-8. PMID 17909702. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Khan FY (2009). "Rhabdomyolysis: a review of the literature". Neth J Med. 67 (9): 272–83. PMID 19841484. {{cite journal}}: Unknown parameter |month= ignored (help)

Camp NE (2009). "Drug- and toxin-induced Rhabdomyolysis". J Emerg Nurs. 35 (5): 481–2. doi:10.1016/j.jen.2009.05.007. PMID 19748039. {{cite journal}}: Unknown parameter |month= ignored (help)

Circéus (talk) 12:58, 6 April 2010 (UTC)

Epidemiology

That section probably needs to be adjusted a bit. A search on exercise induced rhabdomyolysis netted this article (annoying ads, but seemed to link to good sources) that exercise induced rhabdomyolysis may be more common that the article gives it credit for. In addition the rest of the article is similarly focused on trauma causes and should probably be adjusted in light of WP:NPOV#UNDUE. In this case it's not really about the prevalence of viewpoints, but about the prevalence of the causes of the condition. - Taxman ^Talk 16:22, 14 October 2009 (UTC)

That source only focuses on one single cause, and its references are ancient (none after 1990). I'm not very keen on adjusting the section for this. JFW | T@lk 20:41, 14 October 2009 (UTC)

Some of its 'sources' use non-standard definitions. In a formal study, a rhabdo dx typically requires CK at least five times normal, which makes 'If you've ever had stiff and tender muscles after exercising, you've probably had a slight case of rhabdomyolysis' pure hyperbole.

Some 'facts' are quite wrong: For example, women are not 'immune' to rhabdo.[3]

Additionally, it doesn't actually provide any generalizable information about the incidence. Sure: it may be more common among people that ran a marathon within the last day or two, when compared to the general population, but you can't conclude from this statement that running is more likely to produce rhabdo than abusing cocaine, or that more people run marathons than abuse cocaine.

Overall, I agree with JFW; the source is not very useful. WhatamIdoing (talk) 22:00, 14 October 2009 (UTC)

Ok, but that's just one link I got from a google search. There are more and my point was that I think it indicates that good sources would reflect a different prioritization based on the prevalence. I'm not a specialist though, so I'll leave it to those qualified. Just don't miss the potential message because the link is flawed is all I'm saying. - Taxman ^Talk 18:23, 15 October 2009 (UTC)

As far as I can tell, the good sources disagree with your fundamental assertion. Exercise-induced rhabdo is apparently rather uncommon.

What is apparently common is people misapplying the technical term to a situation that is not severe enough to be diagnosed as rhabdo. WhatamIdoing (talk) 18:54, 19 October 2009 (UTC)

Discuss the muscle more?

I've re-read the article and can't help notice there is very little discussion of the consequence of rhabdomyolysis on the muscle tissue itself. As noted above, these can be severe, yet there is not even a suggestion that Rhabdomyolysis can lead to complete loss of muscle function! Circéus (talk) 13:24, 6 April 2010 (UTC)

The sources are quiet about this. From clinical experience it seems that while muscle cells are destroyed, the muscle tissue does seem to heal and regain its contractile power. I am unaware of long-term studies into muscle strength after rhabdomyolysis. Bizarrely, muscle is a relatively poorly studied tissue in medicine! JFW | T@lk 00:46, 11 April 2010 (UTC)

Apparently uncomplicated rhabdomyolysis (if the broader statements found in some of the reviews I noted above are to be followed) seems to elicit little to no linical interest, and would appear to be about as harmless as a minor hematoma or light sprain. I still think some explicit statement to that fact should be put in. Circéus (talk) 01:56, 11 April 2010 (UTC)

I came across an explicit source, though it's in French: Bollaert, PE (1997). Les Rhabdomyolyses (PDF). 15e journées internationales de mises au point en anesthésie-réanimation. Paris: MAPAR. pp. 599–610. ISBN 2-905356-19-7. Les formes modérées, paucisymptomatiques de rhabdomoyolyse guériront spontanément en l'absence de mesures thérapeutiques agressives {{cite conference}}: Unknown parameter |coauthors= ignored (|author= suggested) (help). Circéus (talk) 02:20, 12 April 2010 (UTC)

For those not comfortable with the French, I think this is a reasonable translation of that statement: "Moderate rhabdomyolysis with few symptoms will heal spontaneously in the absence of aggressive therapeutic measures" -- Scray (talk) 15:48, 16 April 2011 (UTC)

We're essentially saying the same about mild hyperCKaemia. JFW | T@lk 21:37, 16 April 2011 (UTC)

Images

We could use an image of urine from someone with rhabdomyolysis. Will take a photo next time I have a case unless someone already has one.Doc James (talk · contribs · email) 08:40, 4 May 2010 (UTC)

Introduction needs Editing

The introduction as it is now reads: "rhabdomyolysis is the breakdown of muscle tissue due to injury." It is true that one cause of rhabdomyolysis is caused by injury, but that is not the only cause. There are many others as well including over-exertion, suddenly and erratic increase in strenous exercise, and even heat stroke. A person who has never encountered this condition before may go to the Wikipedia site and read the first sentence and assume they don't have it because they were not injured. In fact many common cases of rhabdomyolysis are not caused by injury. A more accurate introduction would focus on the condition itself which is simply the breaking down of skeletal muscle tissue and leakage of the contents into the bloodstream.

Again, the introduction needs more editing. The second paragraph states "The disease and its mechanisms were first elucidated in the Blitz of London in 1941.[3]" This statement is misleading. The actual article reads: "In modern English medical literature, the authors of the first detailed report of ARF related to the crush syndrome were Bywaters and Beall. They observed the condition in four victims of the bombing of London during the Battle of Britain in 1940 (7)." The article says "the first detailed report of ARF" - acute renal failure. Acute renal failure is a severe complication of rhabdomyolysis. So a detailed report of people who suffered ARF in the London bombing of 1940 becomes "the first elucidation of the disease and its mechanisms"? I don't think so. —Preceding unsigned comment added by 131.96.91.71 (talk) 13:14, 27 July 2010 (UTC)

To address your points: injury does not need to be physical, and therefore chemical injury is included; the next sentence in the intro says so. What sources have you got that Bywaters and Beall did not elucidate the cascade from crush injury to shock, azotemia and oliguria? I have reverted your changes to the intro for now, because the USA statistics belie the fact that most rhabdomyolysis occurs in earthquakes worldwide and the rates are much higher, and also because it obviated the etymology. JFW | T@lk 19:36, 27 July 2010 (UTC)

Updating

This is a job I've left for much too long, but I've decided to review the content of the article with the help of Bosch. The source has been around for a while, but I've never quite taken the time to implement its main points fully.

I have removed doi:10.1016/S0140-6736(01)05950-5 as a source. It is cited as evidence that tasers cause rhabdomyolysis, but this is an aside in this commentary and speaks only of "mild rhabdomyolysis". Some other unreliable sources will be removed also. JFW | T@lk 21:51, 16 February 2011 (UTC)

Also eliminating the numerous drugs of abuse that have occasionally been linked to rhabdomyolysis. I'm going to restrict the lists to items mentioned by the reviews (CritCare05 and Bosch) unless absolutely vital. JFW | T@lk 22:18, 16 February 2011 (UTC)

The paediatric review linked above (doi:10.1007/s00467-009-1223-9) looks very good also. JFW | T@lk 23:32, 16 February 2011 (UTC)

Schedule for updating:

1.  Done Signs and symptoms - distinguish between mild forms ("hyperCKaemia" still needs covering in "diagnosis")
2.  Done Causes - add the numerous causes mentioned in Bosch but not in CritCare05
3.  Done Pathophysiology - match current content against Bosch
4.  Done Diagnosis - match current content against Bosch, include indications and interpretation of muscle biopsy in unexplained recurrent rhabdomyolysis
5.  Done Treatment - match current content against Bosch
6.  Done Prognosis - match current content against Bosch
7.  Done Epidemiology - match current content against Bosch
8.  Done History - probably complete

This should one day become an FA candidate, but let's bring it up to date first. JFW | T@lk 11:01, 21 February 2011 (UTC)

doi:10.1136/bmj.a2286 needs to replace the Graham source, as it is not a MEDRS in the presence of proper reviews. JFW | T@lk 11:11, 13 April 2011 (UTC)

doi:10.1111/j.1468-1331.2006.01482.x is the European guideline for the diagnosis of fatty acid oxidation deficiencies. It is probably a bit too specialised, but it is more recent than Warren 2002. JFW | T@lk 12:46, 13 April 2011 (UTC)

doi:10.1097/PEC.0b013e31816bc7b7 is another paediatric review, in case Elsayed is insufficient. JFW | T@lk 10:11, 14 April 2011 (UTC)

It covers roughly the same ground as Elsayed and recaps a lot of things we are already citing from Bosch, Vanholder and CritCare. I suggest it is not cited. JFW | T@lk 18:01, 15 April 2011 (UTC)

Cochrane

I had a look through the Cochrane database of systematic reviews (protocol for CVVH review). There are currently no reviews available, just as the only guideline available for rhabdomyolysis seems to be from Finland. That leaves the recent reviews, most of which we seem to have covered now. JFW | T@lk 17:47, 15 April 2011 (UTC)

Copyedit/Nitpicking by Uploadvirus

Hey Doc:

I went through Rhabdomyolysis rather carefully, and compiled the following list of ideas, suggestions, nitpicks, etc. - many of which may be wrong and/or cheesy, etc. In any case, I thought I'd just go ahead and throw them your way, to do with as you see fit. These aside, I must say HELLOVA GREAT JOB - EXCELLENT ARTICLE!

With very best regards, I remain

Your fan: Cliff L. Knickerbocker, MS (talk) 17:57, 17 April 2011 (UTC)

REVIEW [sic] OF RHABDOMYOLYSIS

Respectfully submitted by: Cliff Knickerbocker, M.S. 17 April 2011

LEDE

• Change rhabdomyo to (Gr. rhabdomyo-) and (lysis) to (Gr. -lysis) ... or maybe something like that?

SIGNS AND SYMPTOMS

• Hyper-use of lead(s) to ...
  • "Release of the components of muscle tissue into the bloodstream leads to disturbances in electrolytes, which can lead to nausea, vomiting, confusion, coma or cardiac arrhythmias (abnormal heart rate and rhythm)" ... and then leads to in the very next sentence, etc. All this repetition ... Vary it? Suggestions: "give(s) rise to", "result(s) in", "causes", etc.?

TABLE OF CAUSES

• Hey, where you say ...
  • "Excessive muscle strain or activity: extreme physical exercise (particularly when poorly hydrated), ..."
• ... I might suggest adding - IF someone could find a reliable source - after "poorly hydrated", something like "... or when physically decompensated and/or unaccustomed to exercise", as it has been my (limited) experience that rhabdomyolysis is MUCH more severe after a given quantity of exercise/work in an untrained person than it is following the same exertions in someone previously well-trained or accustomed to vigorous exercise. NOTE: the "effect" also seems MUCH worse after heavy resistance/acute exertion-type anaerobic stuff (i.e. powerlifting, wrestling, fighting) than after aerobics or more prolonged aerobic-type stuff.
  • • TRIVIA => a friend at the University of Arkansas, Dr. Charles Riggs, is a HARDCORE expert on fatty Acyl-CoA dehydrogenase subtype deficiencies. He's also HAS one of them, and has at least one child with one I know of. His e-mail is criggs@uark.edu if you're interested in talking to him about it. Quick link http://coehp.uark.edu/1425.php

PATHOPHYSIOLOGY

• I'm not too crazy about the "structure and flow" of the following passage:
  • "Damage to skeletal muscle may take various forms. Crush injuries damage muscle cells directly, as well as impairing the(ir?) blood supply; other causes may damage muscle cells by interfering with their metabolism. When damaged muscle tissue rapidly fills with fluid from the bloodstream, as well as sodium and chloride," Hmmm.
• Maybe couple commas here in the following sentence (brackets below contain commas where I might put them)?:
  • "Finally, destroyed muscle cells release potassium, phosphate, myoglobin (a heme[,] and therefore iron-containing[,] protein)..."
• You might want to run some of this stuff by the linguistics gurus User:Kwamikagami or User:Tony1 - they would no doubt know for sure.

GENERAL INVESTIGATIONS

• Don't much like this little fragment-thing here below ...
  • "CK levels rise after 12 hours of the initial damage, remain elevated for 1–3 days and then fall gradually ..."
• I'd suggest something closer to: "CK levels are significantly higher at 12 hours after the initial damage, tend to remain at elevated levels for 1-3 days[,] and then to fall gradually". Maybe?
• In the following passage:
  • "High potassium levels (hyperkalemia) tend to be a feature of severe rhabdomyolysis.[1] Electrocardiography may show whether the elevated potassium levels are affecting the conduction system of the heart (such as T wave changes or broadening of the QRS complex).[13] Low calcium levels may be present in the initial stage due to binding of free calcium to damaged muscle cells.[1]"
• The highlighted parenthetical expression above might read better if it was something like "(suggested by T-wave changes and/or broadening of the QRS complex) ... and not sure about that hyphen, but by-God I bet User:Kwamikagami will know!
• I also wondered if you might want to stick in the acronym(s) ECG/EKG (or whatever) after "electrocardiography", and/or the term ("hypocalcemia") after "low calcium levels in the blood"? Or how about inserting (LDH) next to the enzyme name earlier on in the article, and/or the (terms +/- acronyms) for the liver transaminases, and/or FABP, and/or for some others? Stuff like that? Again, just trying to balance "consistency of style", "education", and "flow of the text".
• Also, in the following sentence:
  • "The incidence of actual acute liver injury is 25% in people with non-traumatic rhabdomyolysis[,] although the mechanism for this is uncertain.[1]
• I personally would insert the comma where the brackets are, or I might even reverse the pieces of the sentence =>"Although the mechanism is uncertain, the incidence of actual acute liver injury is 25% in people with non-traumatic rhabdomyolysis" ... Up to you.

COMPLICATIONS

• In this passage:
  • "Disseminated intravascular coagulation, another complication of rhabdomyolysis and other forms of critical illness, may be suspected on the basis of unexpected bleeding or abnormalities on hematological tests" ...
• Just a gut feeling => I'd suggest either of these two ways: "in hematological tests" or "on hematological testing", but not the "mixed form" (so to speak) that you have.
• Gut also tells me to toss out the word "the" in front of "prothrombin time" at the end there (?).

UNDERLYING DISORDERS

• In this passage:
  • "Disorders of glycolysis can be detected by various means, including the measurement of lactate on exercise; a failure of the lactate to rise may be indicative of a glycolysis disorder."
• ... Something about the use of the word on there bothers me - makes it kind of vague (to me, anyway). Do you mean during?
• And myself, I would use EITHER glycolytic disorder OR disorder of glycolysis at the end, but NOT glycolysis disorder. Or I could be aphasic, sorta. Who knows?

Acute Renal Failure Subsection

• You have there:
  • "If kidney dysfunction (acute renal failure, ARF)" ...
• If it were me, I'd move and include the acronym ARF in parentheses WITHIN THE SUBHEADING "Acute renal failure", and NOT "double up" with the comma inside the textual parenthesis, so it looks like this below ...
• Acute renal failure (ARF)
• "If kidney disfunction develops" ... ETC.
• I myself would also change the following passage a bit:
  • "Hemofiltration may be more effective at removing large molecules from the bloodstream, such as myoglobin,[6] but this does not seem to confer particular benefit.[1][3] Peritoneal dialysis may be difficult to administer in someone who has sustained abdominal injury,[3] and is possibly less effective than the other modalities.[1]
• ... to this ...
  • "Hemofiltration may be more effective at removing large molecules (such as myoglobin[6]) from the bloodstream, but this does not seem to confer particular benefit.[1][3]" Peritoneal dialysis may be difficult to administer in someone with serious abdominal injury,[3] and it may be less effective than the other modalities.[1]

EPIDEMIOLOGY

• The below sentence really sucks  :-)
  • "In 1995, USA hospital statistics reported 26,000.[4]"
• You left out the end, and also, the MOS says: "U.S. (with periods) is more common as the standard abbreviation for United States, although The Chicago Manual of Style now deprecates the use of the periods (16th ed.); US (without periods) is generally accepted in most other national forms of English." and it also says: "Do not use U.S.A. or USA, except in a quotation or as part of a proper name (Team USA)."
• OK, yada yada, so maybe that sentence should be:
  • "In 1995, hospitals in the US reported 26,000 new cases of rhabdomyolysis."
• I also would reword the 4th sentence in this section as below:
  • "The risk is higher in patients with a history of illicit drug use, alcohol misuse and trauma compared to those with muscle disease, and has been found to be particularly high if multiple contributing factors occur together.[2]"
• And the last sentence in the first paragraph there has "USA" again - change that to US, or I will tell the MOS police on you.

In case you noticed the changes ... that all read so good (so well?)) when I posted it a while ago, but after re-reading it, I felt forced to "re-tweak" some suggestions above (ex post facto). OK, thats all of this I can take - "the patient is yours", and YOU ARE ON YOUR OWN!

Hmmm ... NO WONDER I'm getting nowhere on my dissertation!!!

Cliff L. Knickerbocker, MS (talk) 21:20, 17 April 2011 (UTC)

Thanks for the comments Cliff, everything is welcome.

• Lead - agreed with recommendation
• Signs & symptoms - totally agree with recommendation and changed an error in the process
• Causes - none of the sources were explicit about the degree of physical fitness protecting from rhabdomyolysis, although Elsayed points out that particular exercises confer a higher risk; there is just not enough space to cover this in a lot of detail. Similarly, we can't dig too deep into the fascinating world of metabolic muscle diseases.
• Pathophysiology - agree with stylistic advice
• Diagnosis - suggestions accepted
• Treatment - I have left the section header alone as I seem to remember that introducing initialisms in the section header is against MOS; with regards to hemofiltration I have phrased this carefully based on Elsayed and Vanholder, and the suggested version changes some of the attributions
• Epidemiology - guilty as charged

JFW | T@lk 21:27, 17 April 2011 (UTC)

More reviews, vicar?

I've done a PubMed search with rhabdomyolysis as a "major" topic and restricted to reviews. Naturally, a lot of reviews are disguised case reports. A few of the others (going back to 2005) are:

• doi:10.1213/​ane.0b013e3181a9d8d9 is a review from anaesthetic perspective on the possible overlap between exercise and heatstroke-induced rhabdomyolysis and malignant hyperthermia - I thought it was too detailed for inclusion (Anesth Analgesia 2008)
• doi:10.1016/j.ejim.2007.06.037 is a general review with a structure that almost looks like it got lifted from our article; it has no additional content (Eur J Intern Med 2008)
• PMID 19841484 is a low impact factor review that covers all we are already discussing (Neth J Med 2007)
• doi:10.1016/j.jbspin.2004.04.010 is very thorough and seems to cover the matter in the same level of detail as Warren and NEJM (Joint Bone Spine 2005) - I may still lift stuff from there after a close read

The peer review is still open, but it is probably time we get this towards FAC when that closes. JFW | T@lk 11:09, 3 May 2011 (UTC)

Mechanism issue

My attention was directed here by the FA nom; I find FA reviews annoyingly cluttered so I will discuss my issues here, if that's okay. Here is my first issue: in the Mechanism section, there is a line saying "those cells that survive react by pumping sodium ions out of the cells in exchange for calcium ions (through the sodium-calcium exchanger)". Is this correct? Normally the sodium-calcium exchanger pumps calcium out driven by the gradient of sodium flowing in. Looie496 (talk) 17:30, 23 May 2011 (UTC)

Vanholder has: "Calcium enters the cell, in exchange for intracellular sodium. Large quantities of free calcium ions trigger persistent contraction, resulting in energy depletion and cell death." Elsayed has a bit less detail. From Warren it appears that the calcium rises due to various different mechanisms. It appears that the Na⁺/Ca⁺⁺-exchanger may work in reverse to remove intracellular sodium, allowing unmitigated influx of calcium. JFW | T@lk 20:16, 23 May 2011 (UTC)

That doesn't make sense to me -- let me do some reading and I'll get back to you on this. Looie496 (talk) 20:21, 23 May 2011 (UTC)

This recent review tells the story pretty clearly, I think. It says that the increase in intracellular Ca has these basic causes: (1) depletion of ATP and loss of membrane integrity cause the sodium-potassium exchange pump to fail, allowing intracellular Na to accumulate; (2) depletion of ATP causes the Ca-ATPase pump to fail, (3) the increase in intracellular Na causes the Na-Ca exchange pump to lose effectiveness. It isn't, to my understanding, that the Na-Ca exchange pump operates in reverse (which is impossible), it is that the pump simply fails to operate effectively, allowing intracellular Ca levels to rise uncontrollably. Looie496 (talk) 20:50, 23 May 2011 (UTC)

While I won't disagree with your interpretation of that literature, I am unsure of your premise that reverse-mode function of Na-Ca exchange proteins is "impossible". For example, PMID 21126331, PMID 21178820, and PMID 20926764 support such activity; in other systems, high extracellular Ca++ can induce other (fascinating) phenomena, i.e. PMID 21187336. -- Scray (talk) 23:08, 23 May 2011 (UTC)

Khan bases his statements on CritCare2005. Many of the sources cite each other (e.g. Bosch citing Warren). Looking through the main sources I cannot find the actual source for what I wrote (this was 2008), and I have therefore changed it. Warren discusses the Na/Ca transporter but not in detail. What I suspect is that a low Na+ gradient (due to high intracellular sodium) stops the exchanger from maintaining low intracellular Ca++. JFW | T@lk 21:03, 23 May 2011 (UTC)

UK or US spelling?

The Bible section contains "traveling" (US) and "travelled" (UK). Aa77zz (talk) 20:14, 23 May 2011 (UTC)

I've been sticking to the US spelling. JFW | T@lk 20:16, 23 May 2011 (UTC)

Haiti

Should the 2010 Haiti earthquake be mentioned in this article? Possible sources include [4] and [5], but the sources are thin, probably because it was so WP:RECENT (relative to the academic publishing schedule). What do you think? WhatamIdoing (talk) 00:27, 24 May 2011 (UTC)

Just glancing over both stories, I can't see much novel about the way the RDRTF handled this, except possibly for the potential scale this could have assumed. I remain open to persuation. JFW | T@lk 19:06, 24 May 2011 (UTC)

Crunch time - the "causes" section

On FAC, both Axl (talk · contribs) and Casliber (talk · contribs) have now stated that the article does not meet WP:WIAFA without a reshuffle of the "causes" section. I have taken this discussion to various places to get a better idea of what people regard as a well-classified list of information (e.g. WT:MED, WT:MEDMOS). The responses have been limited. I am being guided by Axl's suggestion that we take the framework of a good secondary source. He recommended the Oxford Textbook of Medicine and was good enough to provide a table from that source (diff) although I am unsure which edition it was taken from. I have accessed the most recent edition (ISBN 0199204853, 5th edition), which has a similar but different table in chapter 21.5 (box 21.5.4). It uses a grouping that seems to roughly follow the surgical sieve. I am veering towards using the classification of either NEJM (but lifting out the genetic causes for separate treatment) or Warren.

Warren uses (table 1):

• Exertion
• Crush
• Ischemia
• Metabolic
• Extremes of body temperature
• Drugs and toxins
• Infections
• Inflammatory/autoimmune

I do not plan to mention the elaborate subclassification on myocyte level that Warren uses, mainly because it is highly technical and secondly because most of it seems to be based on a degree of speculation. JFW | T@lk 09:13, 5 June 2011 (UTC)

Wow, been doing medicine for over 20 years and had never heard that layout called the surgical sieve - learn something new every day. Okay, I am just digesting this now. Casliber (talk · contribs) 11:07, 5 June 2011 (UTC)

Looking at Warren now - it splits out genetic causes as a separate table, so looks ok on a big-picture level. I note all the numbers and link to "Bold numerals refer to the sites at which regulation of free sarcoplasmic calcium concentration is disrupted " - hmm, does start to raise the dilemma of how much detail is necessary for the lay reader vs absolute. Casliber (talk · contribs) 11:31, 5 June 2011 (UTC)

Coturnism

Due to space constraints the article does not contain a more detailed desciption of the historical and toxicological context of coturnism (rhabdomyolysis after eating quail). I have just discovered doi:10.1001/jama.1970.03170070056017 (JAMA 1970) which traces most of the reports back to the 1940s in Algeria.

Sheredot (talk · contribs) added a reference to a report that suggested that Stachys annua was the toxic plant involved (doi:10.1080/08873638709478507) rather than hemlock. This is not consistent with other reports (doi:10.1503/cmaj.1031256 - CMAJ 2004) that implicates hemlock and Galeopsis laudanum and doi:10.1021/jf902764n (J Agric Food Chem) that exonerates Slachys and Galeopsis.

It would be helpful to have a secondary source available that can support any further additions to the article (see WP:MEDRS). JFW | T@lk 13:31, 24 June 2011 (UTC)

According to Rosner (doi:10.1001/jama.1970.03170090060017), Maimonides (in his aphorisms) reports myalgias after consuming quail. JFW | T@lk 13:33, 24 June 2011 (UTC)

The important point is that the hemlock myth, which has been around for 2,000 years, is known to be false. It is a fundamental point that whatever the poison, or plant source, the quail eat it without ill effect. Any plant that poisons quail must be excluded. This must also throw doubt on using rats as a useful experimental animal. How does one know whether they are like humans or like (migrating) quail. Do quail, as I suspect, have a different metabolism when migrating?Sheredot (talk) 09:13, 26 June 2011 (UTC)

There are subsequent reports that still support the association (see the references provided); I cannot comment on quail metabolism. It has been suggested that human muscle overuse predisposes to coturnism (see the JAMA 1970 report). I am a bit worried that you are prepared to refer the hemlock hypothesis as a "myth" on the basis of a single report. What is the basis for your claim that this hypothesis is 2000 years old? Maimonides lived in the 12th century. JFW | T@lk 13:13, 26 June 2011 (UTC)

These subsequent reports merely assume the hemlock cause they provide no evidence. Problems with hemlock poisoning come in in four areas (1) Hemlock seed kills quail, (2) Hemlock produces a sharp appetite depressant effect in quail, (3) Quail are toxic when hemlock seed is not available for consumption, and (4) Cotumix cannot accumulate toxic elements in hemlock seed. see Toxic quail: A cultural‐ecological investigation of coturnism.Bruce W. Kennedy & Louis Evan Grivetti Ecology of Food and Nutrition Volume 9, Issue 1, January 1980, pages 15-41 Ancient Greeks Aristotle, Galen etc. are c.2000 yrs ago Sheredot (talk) 10:29, 29 June 2011 (UTC)

Clearly the 1980 paper has not discouraged others from attributing the problem to hemlock. You can therefore not go ahead and claim that it is a "myth", because you will be engaging in original research. JFW | T@lk 10:37, 29 June 2011 (UTC)

Crush syndrome

This is a separate article. It also refers to the condition as "Bywater's syndrome". This article ought to be either incorporated, or linked in some way. Amandajm (talk) 13:09, 20 September 2011 (UTC)

Agree that any well-referenced and notable material uniquely in Crush syndrome should be merged into Rhabdomyolysis before the former is deleted and redirected to the latter (but not today, while it's featured on the Main Page). -- Scray (talk) 13:34, 20 September 2011 (UTC)

Crush injury is only one of many causes of rhabdomyolysis. The current version of that article also directly contradicts the historical account given here. I have no problems with merging the two (although a subarticle is not unreasonable), but we would need to form consensus on the historical account. JFW | T@lk 13:37, 20 September 2011 (UTC)

Coturnism contradiction

Checking up on the template addition by a previous editor and adding a discussion area. Separate from the other conversation above about coturnism as a topic in this article, the Contradict-other template appears valid as there is a WP issue with two contradictory articles - coturnism directly contradicts the information given here. Thanks for helping! Universaladdress (talk) 03:30, 20 April 2012 (UTC)

Contradictions should only be tagged if the contradiction occurs within the article. I cannot help the fact that the secondary sources supporting this article suggest one etiology for coturnism, while the editor who wrote the coturnism article seems to believe that his primary sources should be based upon. JFW | T@lk 06:19, 20 April 2012 (UTC)

I have removed the template, simply because it defaces the article. Feel free to suggest modifications to this article here, or alternatively to coturnism. JFW | T@lk 21:22, 21 April 2012 (UTC)

Replacing the template. I think you are mixing this template up with another one - this one clearly refers to contradictions between two articles that must be addressed. If you do not feel you are cut out to address them, please leave this work to someone who is. Finally, you must adhere to what the template says: do not remove without discussion. Thanks again. Universaladdress (talk) 17:52, 28 May 2012 (UTC)

I'm sorry, what exactly is the "contradiction" in question? I don't see anything that would require defacing a featured article in this way. Yobol (talk) 18:06, 28 May 2012 (UTC)

As the editor admits above, the contradiction is on the subject of etiology. Please improve if you have the knowledge. Thanks! Universaladdress (talk) 18:16, 28 May 2012 (UTC)

Please specifically detail what the contradiction is. Making vague remarks does not help. Yobol (talk) 18:18, 28 May 2012 (UTC)

I second this request: my quick review shows no contradiction. WhatamIdoing (talk) 18:26, 28 May 2012 (UTC)

Exertional rhabdomyolysis

doi:10.1097/CND.0b013e31822721ca is a review specifically about exertional RM. The abstract and references look good, but I need to get hold of the fulltext before deciding to include it. JFW | T@lk 01:41, 7 October 2012 (UTC)

I just downloaded a copy, will send you email. -- Scray (talk) 04:12, 7 October 2012 (UTC)

I've still got it in my bag but am struggling to work it into the article in a useful way. JFW | T@lk 16:20, 2 December 2012 (UTC)

Cure?

Is there a cure out for this disease? My fiancee's 7 yr old brother may have this disease. Is there anything out today that will reverse the affects of this? Neurontin/gabapentin maybe? — Preceding unsigned comment added by Sethwede1230(talk • contribs) 21:23, 13 December 2012 (UTC)

We cannot offer medical advice. Please see the medical disclaimer, and contact an appropriate medical professional. -- Scray (talk) 02:33, 14 December 2012 (UTC)

Added Prevention Strategies and my own pictures

just added some more pictures and strategies for prevention.

Treatment posting

Just want to explain why there was an addition to the treatment section. It is part of a project for a college class. Just a heads up! — Preceding unsigned comment added by MikalaB (talk • contribs) 23:25, 21 May 2013 (UTC)

Class (Addition to Causes)

We needed to add our own research to the page for a college class assignment.

Have you guys read the article yet? What you will notice is that all your additions are already there. Please discuss proposed changes here on the talk page. Also please read WP:MEDMOS and WP:MEDRS. WP:MEDHOW will provide more instruction on formating. Please share with your class. Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:29, 22 May 2013 (UTC)

While some of the additions were based on good references (meeting criteria from WP:MEDRS), they were mostly duplicative or overstated the findings from the sources. Perhaps you might consider making suggestions here on the talkpage and awaiting a response from other editors before adding things to the article.

This article is a featured article, which means it was edited collaboratively and approved by the community as being of a very high standard. It is certainly not the same as a "Start class" or "C class" article that can be easily improved by finding some good sources, and there is a high likelihood that additions will be removed quite quickly. Please contact me if you have any questions. JFW | T@lk 14:08, 24 May 2013 (UTC)

Risk score

doi:10.1001/jamainternmed.2013.9774 is a nice paper using data of 1000s of patients to derive and validate a risk score for RRT or death in those with CK>5000 within 3 days of admission. I'm pretty sure that it will very soon be reflected in secondary sources. The risk score is based on age, sex (prognosis worse in females), the initial creatinine, calcium, CK (>40,000 is worse), underlying cause (prognosis better in seizures, syncope, exercise, statins, or myositis), and initial phosphate and bicarbonate.

I won't currently reference the article, but will monitor the secondary sources for mention. JFW | T@lk 11:08, 3 September 2013 (UTC)

This sounds like it's worth including. I'm curious about how sex affects outcome. Hormones? Different kidney status to begin with? I wonder if that risk factor really ought to be "sex" or "weight". A pound of flesh in the median female is a higher proportion of the median adult female's body than the median adult male's. WhatamIdoing (talk) 17:01, 21 January 2014 (UTC)

WhatamIdoing The association came out of multivariate analysis, so association might not imply causation.

I hesitate to include the paper because it is a primary study. It will probably find its way into a secondary source of note. JFW | T@lk 20:51, 21 January 2014 (UTC)