Muscle Enzyme Levels Research Articles

Adolescent with Hypothyroidism Induced Rhabdomyolysis and Acute Kidney Injury

Objectives: Rhabdomyolysis is a potentially life-threatening syndrome. Hypothyroid patients may present with myopathy and mild elevation of CK levels; however, overt rhabdomyolysis is extremely rare, and few cases have been described. Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis. Case report: A 24-year-old young man with accidently discovered hypothyrodism on admission presented with generalized myalgia, profound proximal muscle weakness of the bilateral lower extremities, anuria, vomiting and dark colored urine lasting for three days. Neurological examination revealed bilateral marked weakness and tenderness of muscles of both lower and upper extremities. Urine had dark red appearance and urinalysis showed blood reaction with dipstick test, but there were no erythrocytes on microscopic examination. Serum creatine phosphokinase and myoglobin levels were elevated. Thyroid stimulating hormone (TSH) levels were high, and Free Thyroxine (T4) and Triiodothyronine (T3) levels were low, renal function tests showed acute kidney injury. Other causes of rhabdomyolysis such as muscular trauma, drugs, toxins, infections, vigorous exercise, and electrolyte abnormalities were excluded. Hemodialysis was administered for five sessions. After L-thyroxine therapy, thyroid function tests normalized, muscle strength improved, serum muscle enzyme levels returned to normal levels, and renal function tests recovered. Conclusion: Hypothyroidism should be considered in patients presenting with renal impairment associated with rhabdomyolysis.

Effect of Astaxanthin Supplementation on Salivary IgA, Oxidative Stress, and Inflammation in Young Soccer Players.

The physiologic stress induced by physical activity is reflected in immune system perturbations, oxidative stress, muscle injury, and inflammation. We investigated the effect of astaxanthin (Asx) supplementation on salivary IgA (sIgA) and oxidative stress status in plasma, along with changes in biochemical parameters and total/differential white cell counts. Forty trained male soccer players were randomly assigned to Asx and placebo groups. Asx group was supplemented with 4 mg of Asx. Saliva and blood samples were collected at the baseline and after 90 days of supplementation in preexercise conditions. We observed a rise of sIgA levels at rest after 90 days of Asx supplementation, which was accompanied with a decrease in prooxidant-antioxidant balance. The plasma muscle enzymes levels were reduced significantly by Asx supplementation and by regular training. The increase in neutrophil count and hs-CRP level was found only in placebo group, indicating a significant blunting of the systemic inflammatory response in the subjects taking Asx. This study indicates that Asx supplementation improves sIgA response and attenuates muscle damage, thus preventing inflammation induced by rigorous physical training. Our findings also point that Asx could show significant physiologic modulation in individuals with mucosal immunity impairment or under conditions of increased oxidative stress and inflammation.

Muscle damage and behavioral consequences from prolonged handling of albatross chicks for transmitter attachment

Capture and handling are essential methods for many studies of wild animals but can induce several harmful effects on individuals being studied. The relationship between physiological and behavioral responses in individuals exposed to these effects is not well known. We measured the blood level of muscle enzymes, aspartate aminotrasnsferase (AST) and creatine kinase (CK), indicating muscle damage in hand-reared short-tailed albatross (Phoebastoria albatrus) chicks before and after prolonged restraint for transmitter attachment beyond the usual feeding. We analyzed the relationships between enzyme levels and albatross pre- and post-fledging behaviors. Prolonged restraint for transmitter attachment elevated the blood levels of AST and CK in chicks. In chicks with higher levels of these enzymes, fledging date was earlier and the period to sustained flight after fledging was longer. These results indicated that prolonged handling for transmitter attachment on pre-fledging albatross chicks caused moderate muscle damage and behavioral changes before and after fledging. Although immediate post-fledging survival (the first 2 weeks at sea) did not appear to be affected, whether longer-term survival may be influenced is unknown. Reducing handling time for albatross chicks is important to reduce muscle damage and behavioral consequences. © 2014 The Wildlife Society.

Muscle involvement in Dent disease 2

Dent disease, an X-linked recessive renal tubulopathy, is caused by mutations in either CLCN5 (Dent disease 1) or OCRL (Dent disease 2). OCRL mutations can also cause Lowe syndrome. In some cases it is difficult to differentiate Dent disease 1 and 2 on the basis of clinical features only without genetic tests. Several studies have shown differences in serum levels of muscle enzymes between these diseases. The aim of our study was to test the validity of these findings. In total, 23 patients with Dent disease 1 (Group A), five patients with Dent disease 2 (Group B) and 19 patients with Lowe syndrome (Group C) were enrolled in our study. The serum levels of three muscle enzymes [creatine phosphokinase (CPK), lactate dehydrogenase (LDH), aspartate aminotransferase (AST)], were measured. The levels of a hepatic enzyme, alanine aminotransferase (ALT), were also measured as a control. One patient in Group B had muscle hypoplasia of both upper extremities. The serum levels of all three muscle enzymes assayed were higher in Group B or C patients than in Group A patients. Serum ALT levels were normal in all three groups of patients. The serum levels of muscle enzymes in patients with Dent disease can be used as a biomarker to predict genotypes, even though the patients do not have clinical symptoms of muscle involvement.

Adrenal Insufficiency as a Cause of Loss of Consciousness: A Case Study

Introduction: The current study introduces a case with adrenal insufficiency that was suspected to have congenital adrenal hypoplasia because of undescended testis and failure to thrive due to muscle involvement. Case Presentation: The patient was a 34-month-old boy who had loss of consciousness, hypotension, hypoglycemia, hyponatremia and hyperkalemia with severe failure to thrive, hyper pigmentation of mucosa, hypotonia and no hypospadias. He was resistant to serum therapy and responded to hydrocortisone. Laboratory study elucidated elevated levels of adrenocorticotropin (ACTH) and muscle enzymes, decreased serum cortisol levels. Discussion: Adrenal hypoplasia congenita is a differential diagnosis for adrenal insufficiency. Undescended testis, especially in absence of hypospadiasis, is a clue to diagnose and treat this lethal disease.

Adrenal Insufficiency as a Cause of Loss of Consciousness: A Case Study

Introduction: The current study introduces a case with adrenal insufficiency that was suspected to have congenital adrenal hypoplasia because of undescended testis and failure to thrive due to muscle involvement. Case Presentation: The patient was a 34-month-old boy who had loss of consciousness, hypotension, hypoglycemia, hyponatremia and hyperkalemia with severe failure to thrive, hyper pigmentation of mucosa, hypotonia and no hypospadias. He was resistant to serum therapy and responded to hydrocortisone. Laboratory study elucidated elevated levels of adrenocorticotropin (ACTH) and muscle enzymes, decreased serum cortisol levels. Discussion: Adrenal hypoplasia congenita is a differential diagnosis for adrenal insufficiency. Undescended testis, especially in absence of hypospadiasis, is a clue to diagnose and treat this lethal disease.

Dermatomyositis as a complication of interferon-α therapy: a case report and review of the literature

Autoimmune disorder is one of the important side effects of interferon-α therapy. Some polymyositis cases as complication of interferon-α therapy were reported, but dermatomyositis were rarely. We report a case of dermatomyositis as a complication of interferon-α therapy for hepatitis C. A 52-year-old Japanese man was treated by combination therapy with pegylated interferon-α-2b and ribavirin for hepatitis C. Three months after the initiation of therapy, he showed erythema in the posterior cervical to dorsal and anterior cervical to thoracic regions, weight loss, general malaise, muscle pain, and severe increase in levels of muscle enzymes. We made a diagnosis of dermatomyositis according to these clinical features, proximal muscle-predominant myogenic change on electromyography, and infiltration of monocytes and CD4+-dominant lymphocytes on skin biopsy, although myositis-associated antibodies were absent. He was successfully treated with intravenous immunoglobulin and tacrolimus in addition to glucocorticoid. This is a very rare case of dermatomyositis associated with interferon-α therapy. We reviewed several similar published cases and the association of dermatomyositis and type I interferon.

Enzyme replacement therapy in juvenile glycogenosis type II: a longitudinal study

Glycogenosis type II, a genetic muscle-wasting disorder, results in a spectrum of clinical phenotypes. Enzyme replacement therapy is effective in the infantile form of the disease, while little is known about its effectiveness in late-onset disease, especially in juvenile patients. The purpose of this retrospective cohort study was to assess the long-term effects of enzyme replacement therapy (ERT) in juvenile glycogenosis type II (GSDII). Eight Italian juvenile GSDII patients, receiving biweekly infusions of 20 mg/kg recombinant human α-glucosidase for at least 72 months, were enrolled (median age at therapy start was 11.8 years). Six-minute walk test (6MWT) and forced vital capacity (FVC), measured in upright position, were chosen as the principal outcome measures. Global motor disability (modified Walton scale (WS)), muscle enzymes levels [creatine phosphokinase (CK), lactate dehydrogenase (LDH), aspartate transaminase (AST), alanine transaminase (ALT)] and body mass index (BMI) were also analysed both at baseline (therapy start) and annually afterwards. At baseline, most patients (six out of eight) did not show muscle function impairment (WS ≤ 2). The performance at 6MWT showed a slight improvement during follow-up as well as FVC. Muscle enzymes levels showed a clear decrease after the 1st year of treatment while remained stable afterwards. An overall decrease in BMI was also observed during follow-up, although at the individual level, trends were variable. ERT is effective in stabilising both motor and lung functions in juvenile patients with GSDII, possibly slowing down the rate of disease progression. Randomised controlled trials are needed to understand whether early treatment allows juvenile patients to reach adulthood with a more beneficial residual muscular function than untreated patients.

Acute renal failure in two cases with hypothyroidism related rhabdomyolysis

Introduction: We describe two cases of acute renal failure due to rhabdomyolysis associated with hypothyroidism. Hypothyroidism usually leads to muscular disorders, otherwise rhabdomyolysis is quite rare. Case Series: This case report describes two cases of acute renal failure due to rhabdomyolysis associated with hypothyroidism in a 72-year-old male and a 36-year-old female in whom muscle enzyme levels were typical of rhabdomyolysis. Other reasons of rhabdomyolysis were excluded. Renal functions were recovered in both cases after treatment. Conclusion: Hypothyroidism must be considered in patients presenting with acute renal failure and elevated muscle enzymes even in absence of additional precipitating factor. (This page in not part of the published article.) IJCRI – International Journal of Case Reports and Images, Vol. 5 No. 3, March 2014. ISSN – [0976-3198] IJCRI 2014;5(3):195–197. www.ijcasereportsandimages.com Akin et al. 195 CASE SERIES OPEN ACCESS Acute renal failure in two cases with hypothyroidism related rhabdomyolysis Davut Akin, Sehmus Ozmen

Dermatomyositis associated with hepatitis B virus-related hepatocellular carcinoma

Dermatomyositis is an idiopathic inflammatory myopathy with typical cutaneous manifestations. It has been proposed that dermatomyositis may be caused by autoimmune responses to viral infections. Previous studies have shown an association between dermatomyositis and malignant tumors such as ovarian cancer, lung cancer, and colorectal cancer. However, a chronic hepatitis B virus (HBV) infection associated with dermatomyositis and hepatocellular carcinoma (HCC) has been very rarely reported. Here, we report a rare case of dermatomyositis coinciding with HBV-associated HCC. A 55-year-old male was confirmed to have HCC and dermatomyositis based on proximal muscle weakness, typical skin manifestations, elevated muscle enzyme levels, and muscle biopsy findings. This case suggests that HCC and/or a chronic HBV infection may be factors in the pathogenesis of dermatomyositis through a paraneoplastic mechanism.

Muscle Weakness in a Patient with History of Poliomyelitis: A Differential Diagnosis for Post-polio Syndrome (PPS) and Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory myopathy, characterized by inflammation of the proximal skeletal muscles and typical skin manifestations, which results in symmetric muscle weakness. A 43year-old man was presented with skin rash and left leg weakness, and he had a history of poliomyelitis. Initially, he was diagnosed as having post-polio syndrome (PPS) due to unilateral muscle weakness and a result of an the electromyography (EMG), which had shown patterns of PPS. After 4 months with conservative therapy for PPS, weakness of bilateral upper arms had developed and skin rashes on his entire body had aggravated and progressed. He was diagnosed as having dermatomyositis, based on elevated muscle enzyme levels, typical skin rashes, and typical EMG findings, which indicated muscle disease. When a patient with previous poliomyelitis has a newly developed muscle weakness or pain, we should consider various possible causes other than PPS.

Acute Polymyositis/systemic Lupus Erythematosus Overlap Syndrome with Severe Subcutaneous Edema and Interstitial Lung Disease

Inflammatory myopathy is characterized by symmetrical proximal muscle weakness, elevated muscle enzyme levels and favorable response to glucocorticoids therapy. Although periorbital edema is a common manifestation of inflammatory myopathy, generalized subcutaneous edema is very rare. We report here a case of a 47-year-old female patient with acute polymyositis/systemic lupus erythematosus overlap syndrome with generalized subcutaneous edema and interstitial lung disease. We aggressively treated the disease with high-dose glucocorticoids, intravenous immunoglobulin, and immunosuppressive agents.

Use of rituximab in histologically confirmed idiopathic inflammatory myositis: a case series

The purpose of the study was to undertake an audit of the use of rituximab in refractory idiopathic inflammatory myositis (IIM). Patients with biopsy-proven refractory IIM treated with rituximab, attending the rheumatology clinic at the Royal Adelaide Hospital were identified by searching the electronic database of patient records from 2007 to March 2013. Seven cases (five women, two men), age range 31 to 68 years with histologically confirmed IIM, were identified. All patients had received rituximab following other immunosuppressive agents, including prednisolone. With rituximab, all patients showed improvement in muscle strength and reduction in muscle enzyme levels and required reduced doses of oral corticosteroids. Response continued for at least 5 months from the initial treatment. No serious adverse events were noted, and there were no infections during the study period. This case series supports the use of B cell depletion therapy with rituximab as an effective treatment for patients with refractory IIM.

PReS-FINAL-2131: Hunting for biomarkers in juvenile dermatomyositis

Juvenile Dermatomyositis (JDM) is a systemic autoimmune disorder in which the immune system targets the microvasculature of skeletal muscles, skin and other organs, with for the most part an unknown immunopathogenesis. Moreover, evaluation of disease activity remains challenging in juvenile dermatomyositis as muscle enzyme levels and inflammatory markers, routinely used in clinics, are no reliable biomarkers in JDM, especially for monitoring the disease.

PReS-FINAL-2251: Influenza myositis outbreaks: clinical and laboratory findings

Acute myositis has epidemiologic association with Influenza, presenting with myalgia, weakness, limited mobility, high serum levels of muscle enzymes and leukopenia, in toddlers and school children, mostly in boys. It concerns the parents and puzzles physicians in emergency setting.

Clinical and Laboratory Features Distinguishing Juvenile Polymyositis and Muscular Dystrophy

To differentiate juvenile polymyositis (PM) and muscular dystrophy, both of which may present with chronic muscle weakness and inflammation. We studied 39 patients with probable or definite juvenile PM and 9 patients with muscular dystrophies who were initially misdiagnosed as having juvenile PM. Differences in demographic, clinical, and laboratory results; outcomes; and treatment responses were evaluated by Fisher's exact and rank sum tests. Random forests classification analysis and logistic regression were performed to examine significant differences in multivariable models. Clinical features and serum muscle enzyme levels were similar between juvenile PM and dystrophy patients, except 89% of dystrophy patients had muscle atrophy compared with 46% of juvenile PM patients. Dystrophy patients had a longer delay to diagnosis (median 12 versus 4 months) and were less frequently hospitalized than juvenile PM patients (22% versus 74%). No dystrophy patients, but 54% of juvenile PM patients, had a myositis autoantibody. Dystrophy patients more frequently had myopathic features on muscle biopsy, including diffuse variation of myofiber size, fiber hypertrophy, and myofiber fibrosis (44-100% versus 8-53%). Juvenile PM patients more frequently had complex repetitive discharges on electromyography and a complete response to treatment with prednisone or other immunosuppressive agents than dystrophy patients (44% versus 0%). Random forests analysis revealed that the most important features in distinguishing juvenile PM from dystrophies were myositis autoantibodies, clinical muscle atrophy, and myofiber size variation on biopsy. Logistic regression confirmed muscle atrophy, myofiber fibrosis, and hospitalization as significant predictors. Muscular dystrophy can present similarly to juvenile PM. Selected clinical and laboratory features are helpful in combination in distinguishing these conditions.

Myositis Portends Primary Biliary Cirrhosis: A Case Series

Purpose: Although the presence of anti-mitochondrial antibody (AMA) is 98% specific for primary biliary cirrhosis (PBC), AMA is associated with other autoimmune diseases, including inflammatory myopathies. A recent study in Brain found 23 case reports of concurrent PBC and polymyositis (PM), and only one of autoimmune hepatitis (AIH)-PBC overlap with PM. We present two patients from our institution with AIH-PBC overlap and PM, and discuss their management. Case 1: A 60-year-old woman with sicca syndrome was referred to us for persistently elevated aminotransferase values, immunoglobulin M (IgM) (666mg/dL), and immunoglobulin G (IgG) (1,950 mg/dL). A liver biopsy confirmed Scheuer stage I PBC with AIH, and she was started on prednisone and ursodiol. Concurrent to her PBC diagnosis and before prednisone therapy, she developed progressive proximal muscle weakness. Muscle biopsy, electromyography, and elevated muscle enzyme levels suggested PM. On prednisone, her liver enzyme levels normalized while muscle strength responded to several months of intermittent intravenous immunoglobulin. Three years later, she developed diastolic heart failure, which improved on diltiazem. Her disease was complicated by severe osteoporosis, treated with zoledronic acid, calcium, and vitamin D. Currently, she is doing well on ursodiol 500 mg daily, and prednisone 5 mg every other day. Case 2: A 58-year-old man presented to a neurologist after 1 year of truncal weakness. His muscle biopsy, elevated muscle enzymes, and symptoms suggested PM. He responded to prednisone, but was subsequently referred to hepatology for persistently elevated liver test results (AST 89, ALT 99, ALK PHOS 305). AMA (1:160), IgG (2350 mg/dL) and IgM (402 mg/dL) were elevated. Liver biopsy confirmed stage I PBC with confluent necrosis, suggesting AIH overlap. Prednisone 60 mg daily and ursodiol 500 mg twice-a-day were initiated. After 3 months of treatment, the patient's symptoms improved and liver enzyme activity normalized. Discussion: Although AIH-PBC with PM is an infrequently recognized syndrome, we encountered two such cases. The natural course of AIH-PBC and PM is unknown, but some studies show that PM with concurrent PBC may have a more indolent PM with frequent cardiac involvement, as seen in our first patient. Both patients responded to and are being maintained on prednisone and ursodiol. For PM with AIH, if prednisone treatment alone fails, the addition of immunosuppressive agents given singly or in combination with corticosteroids may be considered. Since corticosteroid use may worsen osteoporosis associated with advanced PBC, assessment of bone density with the potential use of bisphosphonates may be valuable.

Metabolic responses to a 48-h ultra-marathon run in middle-aged male amateur runners

PurposeTo evaluate ongoing metabolic changes during a 48-h competitive run and a 48-h recovery period, with focus on potential health risks exemplified by heart and skeletal muscle damage biomarkers and oxidative stress-related indices.MethodsBlood samples were taken before the race, after 12, 24, and 48 h of running, and after 24 and 48 h of recovery from male amateur runners (N = 7, age 35–59 years, VO2max mean ± SD 57.0 ± 4.0 ml kg−1 min−1, total distance covered 183–320 km). The samples were analyzed for morphology, acid–base and electrolyte balance, iron status, lipid profile, interleukin-6, high-sensitivity C-reactive protein, N-terminal pro-brain-type natriuretic peptide, high-sensitivity cardiac troponin T, non-enzymatic antioxidants, activities of selected enzymes including antioxidant enzymes, and total antioxidant status.ResultsThe sustained ultra-endurance run caused hypocapnic alkalosis with slight hyperkalemia and hypocalcemia, but no hyponatremia. Blood biochemistry showed severe muscle but not liver damage, and an acute inflammatory response. These effects were evidenced by leukocytosis, several fold rises in interleukin-6 and high sensitivity C-reactive protein, extreme elevations in serum levels of muscle enzymes, and marked increases in cardiac biomarker levels. Most of the changes dissolved during the 48 h post-race recovery. Neither the iron pool, nor erythropoiesis, nor pro-oxidant/antioxidant balance were substantially affected.ConclusionsThe changes consequent on the ultra-endurance run do not pose a serious health risk in men who begin their endeavor with ultra-endurance running in mid-life. There is some circumstantial evidence that hyperventilatory hypocapnia may modulate inflammatory response by stimulating the release of interleukin-6 from working skeletal muscles.

Expanding the spectrum of recombination-activating gene 1 deficiency: A family with early-onset autoimmunity

Expanding the spectrum of recombination-activating gene 1 deficiency: A family with early-onset autoimmunity

Perioperative statin therapy for improving outcomes during and after noncardiac vascular surgery

Patients undergoing vascular surgery are a high-risk population with widespread atherosclerosis, an adverse cardiovascular risk profile and often multiple co-morbidities. Postoperative cardiovascular complications, including myocardial infarct (MI), are common. Statins are the medical treatment of choice to reduce high cholesterol levels. Evidence is accumulating that patients taking statins at the time of surgery are protected against a range of perioperative complications, but the specific benefits for patients undergoing noncardiac vascular surgery are not clear. We examined whether short-term statin therapy, commenced before or on the day of noncardiac vascular surgery and continuing for at least 48 hours afterwards, improves patient outcomes including the risk of complications, pain, quality of life and length of hospital stay. We also examined whether the effect of statin therapy on these outcomes changes depending on the dose of statin received. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), MEDLINE via Ovid SP (1966 to August 2012), EMBASE via Ovid SP (1966 to August 2012), CINAHL via EBSCO host (1966 to August 2012) and ISI Web of Science (1946 to July 2012) without any language restriction. We used a combination of free text search and controlled vocabulary search. The results were limited to randomized controlled clinical trials (RCTs). We conducted forwards and backwards citation of key articles and searched two clinical trial Websites for ongoing trials (www.clinicaltrials.gov and http://www.controlled-trials.com). We included RCTs that had compared short-term statin therapy, either commenced de novo or with existing users randomly assigned to different dosages, in adult participants undergoing elective and emergency noncardiac arterial surgery, including both open and endovascular procedures. We defined short-term as commencing before or on the day of surgery and continuing for at least 48 hours afterwards. Two authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. We performed separate analyses for the comparisons of statin with placebo/no treatment and between different doses of statin. We presented results as pooled risk ratios (RRs) with 95% confidence intervals (CIs) based on random-effects models (inverse variance method). We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity. We identified six eligible studies in total. The six Included studies were generally of high quality, but the largest eligible study was excluded because of concerns about its validity. Study populations were statin naive, which led to a considerable loss of eligible participants.Five RCTs compared statin use with placebo or standard care. We pooled results from three studies, with a total of 178 participants, for mortality and non-fatal event outcomes. In the statin group, 7/105 (6.7%) participants died within 30 days of surgery, as did 10/73 (13.7%) participants in the control group. Only one death in each group was from cardiovascular causes, with an incidence of 0.95% in statin participants and 1.4% in control participants, respectively. All deaths occurred in a single study population, and so effect estimates were derived from one study only. The risk ratio (RR) of all-cause mortality in statin users showed a non-significant decrease in risk (RR 0.73, 95% CI 0.31 to 1.75). For cardiovascular death, the risk ratio was 1.05 (95% CI 0.07 to 16.20). Non-fatal MI within 30 days of surgery was reported in three studies and occurred in 4/105 (3.8%) participants in the statin group and 8/73 (11.0%) participants receiving placebo, for a non-significant decrease in risk (RR 0.47, 95% CI 0.15 to 1.52). Several studies reported muscle enzyme levels as safety measures, but only three (with a total of 188 participants) reported explicitly on clinical muscle syndromes, with seven events reported and no significant difference found between statin users and controls (RR 0.94, 95% CI 0.24 to 3.63). The only participant-reported outcome was nausea in one small study,with no significant difference in risk between groups.Two studies compared different doses of atorvastatin, with a total of 145 participants, but reported data were not sufficient to allow us to determine the effect of higher doses on any outcome. Evidence was insufficient to allow review authors to conclude that statin use resulted in either a reduction or an increase in any of the outcomes examined. The existing body of evidence leaves questions about the benefits of perioperative use of statins for vascular surgery unanswered. Widespread use of statins in the target population means that it may now be difficult for researchers to undertake the large RCTs needed to demonstrate any effect on the incidence of postoperative cardiovascular events. However, participant-reported outcomes have been neglected and warrant further study.