Serum Creatine Phosphokinase Levels Research Articles

Amelioration of myocardial ischemia-reperfusion injury by SIRT4 involves mitochondrial protection and reduced apoptosis

Apoptosis and mitochondria dysfunction are key contributors to myocardial ischemia-reperfusion (MI-R) injury. SIRT4, a mitochondrial-localized sirtuin, controls cellular energy metabolism and stress response, and is abundantly present in the heart, however, its role in MI-R injury is not clear. In the current study, we demonstrate that SIRT4 is downregulated in cardiomyocytes both in vitro and in vivo models after MI-R. Functionally, SIRT4 overexpression decreases myocardial infarct size and serum creatine phosphokinase (CPK) level, and vice versa, SIRT4 depletion by siRNA increases myocardial infarct size and serum CPK level. Furthermore, we show that these protective roles of SIRT4 against MI-R injury are associated with preserved mitochondrial function and reduced myocardial apoptosis. Taken together, our findings indicate that SIRT4 ameliorates MI-R injury through regulating mitochondrial function and apoptosis, and suggest that manipulating SIRT4 may be of clinical benefit in MI-R injury.

Case report: lactic acidosis and rhabdomyolysis during telbivudine and tenofovir treatment for chronic hepatitis B

BackgroundCurrent treatment options for chronic hepatitis B (CHB) are pegylated interferon alpha and nucleoside analogues (NAs). NAs have relatively fewer side effects than interferon alpha, and generally well tolerated. Previously 12.9% of patients on telbivudine treatment were reported to develop severe elevation of serum creatine phosphokinase (CPK) levels, but related clinical disease, like lactic acidosis (LA) and rhabdomyolysis (RM) were rare. The pathophysiology may be mitochondrial toxicity, for the NAs inhibit not only hepatitis B virus (HBV) polymerase, but also the host mitochondrial DNA polymerase γ. As mitochondria are the main sites of oxidative phosphorylation, there will be an increase of pyruvate reduction to lactic acid and insufficient adenosine triphosphate. The accumulation of lactic acid causes LA, while lack of energy leads to cell dysfunction and mitochondria-associated disease, including RM. All five NAs, except tenofovir, have been reported causing LA and RM. Here we report the first case of CHB patients developing fatal LA and RM during telbivudine and tenofovir treatment.Case presentationThe patient is a 51-year-old man who was hospitalized in November 2015. He had taken telbivudine regularly because of CHB. Later, tenofovir was added to antiviral treatment because of HBV resistance. Then he had myalgia, chest tightness and anorexia. The blood lactate was 12.7 mmol/L. The arterial blood gas analysis showed pH 7.25, base excess 21.1 mmol/L. CPK was 991 U/L, myoglobin was 1745 ng/ml and creatine was 83 μmol/L. Abdomen magnetic resonance revealed cirrhosis. Muscle biopsy revealed myogenic lesion with abnormality of mitochondria and fat metabolism. The patient was diagnosed with Hepatitis B envelope Antigen positive CHB, cirrhosis, LA and RM characterized by myalgia and elevated myoglobin. He was given tenofovir alone as antiviral treatment instead. After hemodialysis and 4 weeks` treatment of corticosteroids, his symptoms recovered, and blood lactate gradually returned to a normal range.ConclusionsThis case shows that tenofovir may trigger muscle damage and fatal RM in combination with telbivudine treatment in CHB patients. Thus, patients receiving tenofovir and telbivudine should be closely monitored for muscular abnormalities, blood lactate level and other mitochondrial toxicity associated side effects.

Predictive factors for major postoperative complications related to gastric conduit reconstruction in thoracoscopic esophagectomy for esophageal cancer: a case control study

BackgroundRegardless of developments in thoracoscopic esophagectomy (TE), postoperative complications relative to gastric conduit reconstruction are common after esophagectomy. The aim of the present study was to evaluate the predictive factors of major complications related to gastric conduit after TE.MethodsFrom 2006 to 2015, 75 patients with esophageal cancer who underwent TE were evaluated to explore the predictive factors of major postoperative complications related to gastric conduit.ResultsPatients with major complications related to gastric conduit had a significantly longer postoperative hospital stay than patients without these complications (P < 0.01). Multivariate analysis demonstrated that three-field lymph node dissection (3FLND) and high serum levels of creatine phosphokinase (CPK) and C-reactive protein (CRP) at 1 postoperative day (1POD) after TE were significant predictive factors of major complications related to gastric conduit [odds ratio (OR) 5.37, 95% confidence interval (CI) 1.41–24.33, P = 0.02; OR 5.40, 95% CI 1.60–20.20, P < 0.01; OR 5.07, 95% CI 1.47–20.25, P = 0.01, respectively]. The incidence rates of major complications related to gastric conduit for 0, 1, 2, and 3 predictive factors were 5.3%, 18.8%, 58.8%, and 85.7%, respectively (P < 0.01).ConclusionsTwo or more factors in 3FLND and the high levels of CPK and CRP at 1POD after TE were identified as the risk model for major complications related to gastric conduit after TE.Trial registrationUMIN Clinical Trials Registry, ID: UMIN000024436, Registered date: Oct/17/2016.

Severe non-exertional rhabdomyolysis from weight loss supplement in sickle cell trait: A perfect storm?

Exertional rhabdomyolysis from sickle cell trait has been documented. Also, cases of rhabdomyolysis from the use of weight loss supplements in the setting of sickle cell trait and exertion have been described. However, the role of sickle cell trait in non-exertional rhabdomyolysis is not clear. We present a case of severe non-exertional rhabdomyolysis from weight loss supplement in a patient with sickle cell trait.A 45-year-old African American female with sickle cell trait presented to the emergency department with two days history of fatigue and mild breathlessness. She also reported diarrhea and vomiting for five days before presentation. She admitted to taking Garcinia cambogia (a dietary supplement) for weight loss one week prior to the onset of symptoms. She denied alcohol or drug use, rigorous physical activity or trauma.She was dehydrated on examination. Laboratory values revealed markedly elevated serum creatine phosphokinase (CPK) and creatinine levels. Garcinia cambogia was discontinued and she was hydrated with intravenous fluids. Her CPK and creatinine levels significantly trended down and she was discharged home with no apparent sequelae.Our patient had multiple episodes of diarrhea and vomiting likely from the use of Garcinia cambogia. We believe she suffered non-exertional rhabdomyolysis from dehydration in the setting of sickle cell trait. Though dietary weight loss supplements are marketed as generally safe, this case suggests otherwise. We emphasize that clinicians routinely inquire about use of these supplements and provide appropriate counseling to patients on the adverse effects, especially among those with sickle cell trait.

STUDY OF LEVELS OF SERUM CREATINE PHOSPHOKINASE AND LIVER ENZYMES AS A PROGNOSTIC INDICATORS IN ACUTE ORGANOPHOSPHORUS POISONING

Background: Organophosphorus (OP) poisoning is one of the most common poisoning in rural and in developing country. Due to their easy availability and cost effective it is used frequently for homicidal and suicidal attempts. Routinely used biochemical markers like Erythrocyte cholinesterase (EChE) and Plasma cholinesterase (PChE) are used for the diagnosis of acute organophosphorus (OP) poisoning but estimation of these are very costly and not easily available. The mortality increases with increase in initial creatine phosphokinase level and can be used as alternative biomarker. Hence study was done to estimate levels of serum Creatine Phosphokinase (CPK) and liver enzymes in acute OP poisoning patients and its prognostic significance. Methodology: Patients (80) admitted in our hospital were included in this study. A brief history and detailed clinical examination was performed and patients were categorized on the basis Modified Dreisbach’s clinical criteria classification. Serum levels of Creatine kinase (CK) and Liver enzymes were analysed at the time of admission. The outcome of the patients were observed. Results: Out of 80 patients recruited for the study, 41 cases (51.3%) were females, and 39 cases (48.8%) were males. Majority of them were in the age group of 21-30 years. More cases of OP poisoning were among agriculturalists 28 (35%) and housewife 21 (28.8%) and among students 15 (18.8%). Malathion was the most common compound used followed by Monocrotphos. 60% had mild, 31.3% had moderate and 8.8% had severe poisoning. There is increase in Creatine Phosphokinase (CPK) levels in 6 patients who survived with ventilator support and also in 2 patients who died with ventilator support which was statistically highly significant (p<0.05). Serum liver enzymes were within normal limits. Conclusion: Elevated Creatine kinase is commonly seen in OPC poisoning. High initial serum Creatine Phosphokinase (CPK) levels are associated with severe degree of poisoning and are associated with complications and mortality. Serum liver enzymes (SGOT AND SGPT) are not elevated in OP poisoning.

Spontaneous pneumomediastinum in dermatomyositis: a case series and literature review

OBJECTIVES: To describe a case series of spontaneous pneumomediastinum in dermatomyositis and to review the literature. METHODS: This was a retrospective single-center case series, reporting 9 patients with pneumomediastinum and defined dermatomyositis, followed from 2005 to 2017. RESULTS: Median age of patients: 33 years; cutaneous and pulmonary involvement in all cases; constitutional symptoms in 88.8% of patients; involvement of the joints in 11.1%, gastrointestinal tract in 44.4%, and muscles in 77.7%; subcutaneous emphysema was observed in 55.5% and pneumothorax in 11.1%, respectively. Muscle weakness was observed in 77.7% of cases and with a median level of serum creatine phosphokinase of 124U/L. Drawing on results for our literature review, the overall analysis showed that the risk factors associated with spontaneous pneumomediastinum were: (a) a history of interstitial pneumopathy; (b) normal or low levels of muscle enzymes; (c) previous use of systemic glucocorticoid; (d) over 50% of patients had subcutaneous emphysema; (e) high mortality as a consequence of severity of the interstitial lung disease. CONCLUSIONS: Our case series revealed that pneumomediastinum is a rare complication in dermatomyositis that occurs in patients with a history of interstitial pneumopathy and may be accompanied by subcutaneous emphysema and pneumothorax.

Creatinephosphokinase in organophosphorus poisoning

Background: Organophosphorus Poisoning has been found to be a major cause of death or morbidity in our country as it freely available without need of prescription unlike in developed countries where prescription is required to purchase insecticides, the various organophosphorus compounds available are Malathion, parathion, diazinon, fenthion, dichlorvos, chlorpyrifos, ethion. Erythrocyte cholinesterase (EchE) and pseudocholinesterase (Butyryl cholinesterase-BchE) are markers used for assessing the severity in OP poisoning, but estimation of these are costly, has variable values for different individuals and is not available at all centers. This study was done to estimate levels of serum Creatine Phosphokinase (CPK)serially in acute OP poisoning patients and to correlate with prognosis.Methods: 50 patients of organophosphorus poisoning admitted to Mcgann hospital attached to Shimoga institute of medical sciences Shimoga over a period of 6 months from 1st July 2016 to 31st December 2016 were taken up for the study. A comprehensive history and detailed clinical examination was performed and patients were clinically evaluated for severity. Level of serum cholinesterase and serum CPK were estimated at admission and CPK level was measured on day 3 and day 5. The outcome of these patients was evaluated.Results: Out of 50 patients, 78% (n=39) were males and 22% (n=11) were females. Majority of patients were in the age group 21 – 40 years. Chlorpyrifos was the most common compound used. 72% had mild, 20% had moderate and 8% had severe poisoning. Serial measurements of serum CPK levels showed significant correlation with the severity of acute OP poisoning patients. The CPK levels showed a sensitivity of 74% and a specificity of 81% with a positive predictive value of 92%.Conclusions: Severe organo phosphorus poisoning is correlated with CPK levels. This study recommends CPK level estimation in assessment of severity and prognosticate patients with organophosphorus compound as alternate marker to choline esterase.

English

This study aimed to assess the correlation of serum lactate and creatine phosphokinase (CPK) levels, and their association with severity of organophosphrus poisoning in order to use one of them or both as tools in predicting prognosis. This study was conducted over one year and 68 organophosphate (OP)-poisoned patients were enrolled. Clinical severity of cases was categorized according to Peradeniya organophosphorus poisoning (POP) scale. Levels of serum acetyl choline esterase (AChE), serum CPK and serum lactate were measured on admission (0 h), 6 and 24 h post-ingestion. The results showed a high statistically significant difference between cases and control regarding AChE, CPK and lactate on admission. Also, there was high statistically significant difference regarding AChE, CPK and lactate among different categories of cases on admission, 6 and 24 h post admission. In addition, there was a statistically significant increase among different categories of POP scale regarding the quantity of atropine used in management of cases. Regarding oximes and stay in ICU, there was a statistically significant increase in severe poisoned patients when compared with moderate poisoned ones. A significant negative correlation was observed between AChE and severity of poisoning as well as significant positive correlation between CPK and lactate. It is concluded that serum CPK and serum lactate can be used as predictor of outcomes in OP poisoning and helps in determining cases that need follow up. Serum CPK and serum lactate can be used as predictors of outcomes in OP poisoning and helping in determining the cases that need follow up. Key words: Organophosphrus poisoning, serum lactate, predicting prognosis, serum, admission.

Lipid-lowering agent-triggered dermatomyositis and polymyositis: a case series and literature review.

Lipid-lowering agent-triggered dermatomyositis (DM) or polymyositis (PM) is a rare event. Therefore, the aim of the present study was to describe a series of such cases. A retrospective cohort study of 5 DM and 4 PM cases triggered by prior exposure to lipid-lowering agents between 2001 and 2017 was carried out. All patients, except for two cases, had muscle biopsy compatible with inflammatory myopathy and no serum autoantibodies positive for anti-SRP or anti-HMGCoAR. Median age of the patients at time of diagnosis was 68years. Seven patients had previously taken simvastatin 20mg/day (exposure period from 2days to 4years) and two bezafibrate 100mg/day (3-4months). Median time from symptom onset to disease diagnosis was 6months. All patients with DM had a heliotrope and/or Gottron's papules. All patients had symmetrical, predominantly proximal muscle weakness of limbs, with median serum creatine phosphokinase of 3087U/L (interquartile 25-75% range 1293-13,937U/L). All patients received glucocorticoid and immunosuppressants. Complete reversal of clinical symptoms and normalization of serum creatine phosphokinase level occurred within a median of 12months after starting the treatment. There was disease relapse in three cases, and one case of death was unrelated to the disease (pulmonary infectious complications resulting from lymphoma). In contrast to cases described in the literature, the patients in the present study had a relatively more aggressive course, requiring glucocorticoids and immunosuppressants, in addition to a tendency for a longer period to achieve disease remission.

Physical performance in newly diagnosed hypothyroidism: a pilot study.

Hypothyroidism is complicated by neuromuscular symptoms (myalgias, slowness of movements, and tiredness) and signs (easy fatigability and cramps), which may have a negative impact on general well-being and quality of life. In a pilot, prospective, controlled study, we investigated the features of muscle dysfunction in hypothyroidism by disease questionnaire, biochemical measures, and physical performance tests. Fifty-seven consecutive patients with newly diagnosed hypothyroidism were enrolled, 27 subclinical (S-Hypo) and 30 overt (O-Hypo). A series of 30 euthyroid subjects, with similar demographic characteristics, served as controls. Patients were administered a short disease questionnaire and underwent laboratory exams and standardized physical tests, both at baseline and after restoration of biochemical euthyroidism. Compared to euthyroid controls, the O-Hypo group showed significantly higher prevalence of neuromuscular symptoms and significantly higher serum creatine phosphokinase (CPK) levels (p value < 0.0001). S-Hypo had slightly higher CPK levels and prevalence of neuromuscular symptoms than controls. Both S-Hypo and O-Hypo patients performed worse than controls in the six-minute walking test. Differences between patients and controls in handgrip strength test and timed chair standing test failed to reach statistical significance (although a trend was noticeable), possibly due to the small sample size. In O-Hypo, an inverse correlation was found between CPK levels and the handgrip strength test (p value < 0.001). Restoration of euthyroidism was associated with normalization of questionnaire responses, six-minute walking test, as well as serum CPK levels. In addition to neuromuscular symptoms, hypothyroidism is associated with abnormalities of physical performance. The six-minute walking test is the most valuable test to assess this aspect. In the pilot study, levothyroxine therapy could reverse muscle functional abnormalities.

Subcutaneous immunoglobulins for the treatment of a patient with antisynthetase syndrome and secondary chronic immunodeficiency after anti-CD20 treatment: a case report

BackgroundAntisynthetase syndrome is a rare and debilitating multiorgan disease characterized by inflammatory myopathy, interstitial lung disease, cutaneous involvement, and frequent chronic inflammation of the joints. Standard treatments include corticosteroids and immunosuppressants. In some cases, treatment resistance may develop. Administration of immunoglobulins intravenously is recommended in patients with drug-resistant antisynthetase syndrome.Case presentationHere, we describe the case of a 56-year-old woman of Algerian origin. She is the first case of a patient with multidrug-resistant antisynthetase syndrome featuring pulmonary involvement and arthropathy, and chronic secondary immune deficiency with recurrent infections, after anti-CD20 treatment, in which her primary antisynthetase syndrome-related symptoms and secondary immune deficiency were treated successfully with subcutaneous administration of immunoglobulin. The administration of immunoglobulin subcutaneously was introduced at a dose of 2 g/kg per month and was well tolerated. Clinical improvement was observed within 3 months of initiation of subcutaneous administration of immunoglobulin. After 22 months of treatment, she showed a significant improvement in terms of muscle strength, pulmonary involvement, arthralgia, and immunodeficiency. Her serum creatine phosphokinase and C-reactive protein levels remained normal. Finally, she was compliant and entirely satisfied with the treatment.ConclusionsTaken together, these observations suggest that administration of immunoglobulin subcutaneously may be a useful therapeutic approach to tackle steroid-refractory antisynthetase syndrome while ensuring minimal side effects and improved treatment compliance. This treatment also allowed, in our case, for the regression of the chronic immunodeficiency secondary to rituximab treatment.

Craniopharyngioma presenting with severe hyponatremia, hyponatremia-induced myopathy, and panhypopituitarism: a case report

BackgroundCraniopharyngiomas are rare intracranial tumors commonly presenting with neurological symptoms. Reports of severe hyponatremia as a presenting manifestation of a craniopharyngioma and hyponatremia-induced myopathy are rare. We report the case of a patient with craniopharyngioma presenting with severe hyponatremia, panhypopituitarism, and hyponatremia-induced myopathy.Case presentationA 52-year-old Sri Lankan man presented with anorexia, nausea, fatigue, generalized muscle weakness, and cramps for 1 week. The onset of his illness had been preceded by vomiting and diarrhea for 1 day which he attributed to food poisoning. On examination, he had an apathetic disposition with a generalized “sallow complexion.” He was not dehydrated. Apart from reduced muscle power (4/5) and hyporeflexia, the neurological examination was normal. His serum sodium was 102 mmol/l; potassium 4.1 mmol/l; chloride 63 mmol/l; plasma osmolality 272 mosm/KgH2O; urine osmolality 642 mosm/KgH2O; and urine sodium 79 mmol/l. His creatine phosphokinase was 12,400 U/l, lactate dehydrogenase 628 U/l, aspartate aminotransferase 360 U/l, and alanine aminotransferase 64 U/l. His hormone profile revealed panhypopituitarism. An electromyogram showed nonspecific abnormalities while a muscle biopsy did not show any pathology. Magnetic resonance imaging of his brain demonstrated a well-defined craniopharyngioma with suprasellar extension. His pituitary gland was compressed and the pituitary stalk was displaced by the tumor. He had marked improvement in muscle power and rapid reduction of serum creatine phosphokinase levels paralleling the correction of severe hyponatremia, even before the initiation of hormone replacement.ConclusionsThis case illustrates the rare presentation of severe hyponatremia and hyponatremia-induced myopathy in patients with craniopharyngioma, awareness of which would facilitate early appropriate investigations and treatment.

Is rhabdomyolysis an anaesthetic complication in patients undergoing robot-assisted radical prostatectomy?

BACKGROUND:In patients undergoing robot-assisted radical prostatectomy (RARP), pneumoperitoneum, intraoperative fluid restriction and prolonged Trendelenburg position may cause rhabdomyolysis (RM) due to hypoperfusion in gluteal muscles and lower extremities. In this study, it was aimed to assess effects of body mass index (BMI), comorbidities, intra-operative positioning, fluid restriction and length of surgery on the development of RM in RARP patients during the perioperative period.SUBJECTS AND METHODS:The study included 52 American Society of Anesthesiologists I–II patients aged 50–80 years with BMI >25 kg/m2, who underwent RARP. Fluid therapy with normal saline (1 ml/kg/h) and 6% hydroxyethyl starch 200/05 (1 ml/kg/h) was given during the surgery. Charlson comorbidity index (CCI), operation time (OT) and Trendelenburg time (TT) were recorded. Blood samples for creatine phosphokinase (CPK), blood urea nitrogen, creatinine (Cr), aspartate aminotransferase (AST), alanine transferase (ALT), lactate dehydrogenase (LDH), creatinine kinase-MB, cardiac troponin I and arterial blood gases were drawn at baseline and on 6, 12, 24 and 48 h. RM was defined by serum CPK level exceeding 5000 IU/L.RESULTS:Seven patients met predefined criteria for RM. There were positive correlations among serum CPK and Cr, AST, ALT and LDH levels. However, there was no significant difference in BMI, OT and TT between patients with or without RM (P > 0.05). CCI scores were higher in patients with RM than those without (3.00 ± 0.58 vs. 2.07 ± 0.62; P < 0.01). No renal impairment was detected among patients with RM at the post-operative period.CONCLUSIONS:It was found that comorbid conditions are more important in the development of RM during RARP rather than BMI, OT or TT. Patients with higher comorbidity are at risk for RM development and that this should be kept in mind at follow-up and when informing patients.

Delonix regia Leaf Extract (DRLE): A Potential Therapeutic Agent for Cardioprotection.

Delonix regia (Boj. Ex. Hook) is a flowering plant in the pea family found in tropical areas and its leaves are used informally to treat diseases in folk medicine. However, the cardioprotective effects in this plant are still unclear. In this study, we found that the Delonix regia leaf extract (DRLE) (400 mg/kg/d) can reduce the mortality rate in an isoproterenol (ISO)-induced heart injury and hypertrophy mouse model. Decreased serum levels of creatine phosphokinase, LDH, GOT, TNF-alpha and increased nitric oxide levels were found in DRLE-treated ISO-injured mice. In the in vitro study, the porcine coronary artery exhibited vasodilation effect induced by DRLE in a dose-dependent manner. In the DRLE toxic test, overdose of DRLE showed the high safety in normal mice and may have the ability to remove the metabolic wastes in blood. In conclusion, we demonstrated for the first time that DRLE has the cardioprotective effects by activating the vasodilation through NO pathway and preventing the myocyte injury via inhibition of TNF-alpha pathway. We suggest that DRLE may act as a promising novel herbal medicine for cardioprotection.

Markers of muscle damage for comparing soft tissue injury following proximal femur nail and dynamic hip screw operations for intertrochanteric hip fractures

BackgroundFemoral neck fractures are the most common fractures among the elderly. The two operative approaches used for the treatment of AO/OTA 31 intertrochanteric fractures include an intramedullary device (proximal femoral nail [PFN]) or an extramedullary device (sliding/dynamic hip screw [DHS]). The aim of this study was to provide objective evidence of local soft tissue injury by measuring serum creatine phosphokinase (CPK), a biochemical marker, to quantify muscle damage and inflammation in patients treated by the two approaches. Patients and methodsMedical data of 359 patients operated for intertrochanteric fractures with PFN (156 patients) or DHS (193 patients) were retrospectively reviewed. The fractures were classified according to AO/OTA classification. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum CPK and serum hemoglobin (Hb) levels were measured preoperatively and on postoperative day 1 (POD1). Independent predictors of elevation in the levels of markers of inflammation and muscle damage were determined by a multivariate linear regression model. ResultsThe demographics were similar for the two groups. Our study population included 64.2% female patients. Preoperative serum CPK levels were available for 89 patients and POD1 serum CPK levels were available for all patients. One-hundred and thirteen of the 193 DHS patients (58%) and 14 of the 156 PFN patients (9%) had a stable fracture (AO/OTA 31A1, p<0.0001). The DHS patients had a greater increase between pre- and postoperative CPK levels compared to the PFN patients (DHS, δ=368 versus PFN, δ=65, p<0.0002). The PFN patients had a greater decrease in both the pre- and postoperative Hb levels compared to the DHS patients (Diff_Hb 0.27g/dl). The older the patient, the greater decreases in Diff_CPK compared to the younger ones. ConclusionsImplementation of POD1 CPK blood levels as a biochemical marker of soft tissue injury provided quantitative evidence that patients whose intertrochanteric fracture was stabilized by a DHS suffered greater soft tissue injury compared to patients whose fracture was stabilized by a PFN.

MUSCULAR DYSTROPHIES

Objectives: Muscular dystrophies are classified into different types based ontheir age of onset, clinical severity, rate of progression, distribution of muscles weakness,pattern of inheritance and the genes involved. As muscular dystrophies are relativelyuncommon disorders, very little work has been done in Pakistan. This study has classified (forthe first time in Pakistan) the patients with different types of muscular dystrophies by clinicaland biochemical correlation. Study Design: Observational, descriptive study. Setting:Departments of Morbid Anatomy and Histopathology and Human Genetics and MolecularBiology at University of Health Sciences Lahore. Period: Three years’ (March, 2012-March2015). Methodology: A total of 100 patients comprising of all age groups and both gendersand with strong clinical suspicion of muscular dystrophy, with or without positive family history,were included. Detailed clinical history and physical examination findings were recordedfollowed by estimation of serum Creatine Phosphokinase (CPK), Lactate Dehyrogenase(LDH) and Aldolase levels. Results: A total of 77 males (M) and 23 females (F) were included.Mean age of the patients was 12.1990 + 6.69913 years. Parents of 76 patients reported withconsanguineous marriages while positive family history was reported in 31 patients. Eightytwo cases managed to ambulate with support of other persons while n= 14 patients weretotally non ambulatory. Symmetrical muscle involvement (lower limb followed by upper limb)was shown by 87 cases (including all males and n=22 females). Involvement of the lowerlimbs as a primary weakness followed by symmetrical and severe involvement of the upperlimb girdle and lower limb girdle suggested limb girdle muscle dystrophy (LGMD) in 9 (6F,3M)patients. Involvement of shoulders and upper limbs as a primary weakness followed by facialmuscles and infrequent involvement of lower limbs suggested fascioscapulohumeral muscledystrophy (FSHMD) in 2 cases. Involvement of upper limbs as a primary weakness followedby lower limbs with a moderate rise in CPK levels and mild phenotype was seen in two femalepatient which was quite suggestive of dysferlinopathy. Only two male patients reported onsetof weakness and ambulation loss before 1 year of age that may represent congenital muscledystrophy (CMD), dystroglycanopathy or congenital onset of LGMD (cLGMD). Mean serumCPK, LDH and Aldolase levels were 2376.6364 + 910.78963 U/L, 1030.7800 + 180.1620 U/Land 10.089 + 1.525 U/L respectively that demonstrated significant association (p&lt;0.05) withcharacteristic clinical features. Conclusion: Muscular dystrophies are not only restrictedto dystrophinopathies in our population. Apart from clinical and biochemical parameters,appropriate histological and/or gene mutation analysis is mandatory for precise classificationof these disorders.

Use of Cold-Water Immersion to Reduce Muscle Damage and Delayed-Onset Muscle Soreness and Preserve Muscle Power in Jiu-Jitsu Athletes.

Cold-water immersion (CWI) has been applied widely as a recovery method, but little evidence is available to support its effectiveness. To investigate the effects of CWI on muscle damage, perceived muscle soreness, and muscle power recovery of the upper and lower limbs after jiu-jitsu training. Crossover study. Laboratory and field. A total of 8 highly trained male athletes (age = 24.0 ± 3.6 years, mass = 78.4 ± 2.4 kg, percentage of body fat = 13.1% ± 3.6%) completed all study phases. We randomly selected half of the sample for recovery using CWI (6.0°C ± 0.5°C) for 19 minutes; the other participants were allocated to the control condition (passive recovery). Treatments were reversed in the second session (after 1 week). We measured serum levels of creatine phosphokinase, lactate dehydrogenase (LDH), aspartate aminotransferase, and alanine aminotransferase enzymes; perceived muscle soreness; and recovery through visual analogue scales and muscle power of the upper and lower limbs at pretraining, postrecovery, 24 hours, and 48 hours. Athletes who underwent CWI showed better posttraining recovery measures because circulating LDH levels were lower at 24 hours postrecovery in the CWI condition (441.9 ± 81.4 IU/L) than in the control condition (493.6 ± 97.4 IU/L; P = .03). Estimated muscle power was higher in the CWI than in the control condition for both upper limbs (757.9 ± 125.1 W versus 695.9 ± 56.1 W) and lower limbs (53.7 ± 3.7 cm versus 35.5 ± 8.2 cm; both P values = .001). In addition, we observed less perceived muscle soreness (1.5 ± 1.1 arbitrary units [au] versus 3.1 ± 1.0 au; P = .004) and higher perceived recovery (8.8 ± 1.9 au versus 6.9 ± 1.7 au; P = .005) in the CWI than in the control condition at 24 hours postrecovery. Use of CWI can be beneficial to jiu-jitsu athletes because it reduces circulating LDH levels, results in less perceived muscle soreness, and helps muscle power recovery at 24 hours postrecovery.

A Nutraceutical Composition Decreases CPK Levels in Saos-2 Cells and in Patients with Elevated Serum Levels of This Enzyme

Objectives: This study aimed to investigate the effects of a nutraceutical composition on the expression of some genes involved in muscle cells and functioning in osteoblast cells. The effects of nutraceutical composition have been compared to the effects of atorvastatin, which induces muscle pain and elevated creatine phosphokinase (CPK) serum level when administered to patients. In particular, we analyzed the MyoD-1 gene, which is responsible for modulation of the CPK gene, which is a marker of muscle pain and damage. Methods: The effects of nutraceutical composition on Saos-2 cells were compared with the effects of atorvastatin. The mRNAs were extracted and the expression levels of mitochondrial and cytoplasmic CPK genes and MyoD-1 were analyzed by real-time polymerase chain reaction (RT-PCR). Moreover, the effects on lactate dehydrogenase (LDH) activity and adenosine triphosphate (ATP) synthesis were measured in the osteoblast cell line. Furthermore, 11 patients with muscle pain or elevated CPK serum levels received a supplementation of the nutraceutical composition to test whether CPK levels could be downregulated. Results: The analysis in Saos-2 cells showed that the nutraceutical composition upregulates the gene expression of MyoD-1 and downregulates the expression of the cytoplasmic isoform of CPK gene expression (p ≤ 0.05); moreover, it slightly increases ATP amount and decreases LDH activity. Conversely, atorvastatin represses the expression of MyoD-1 gene without significant changing into the expression levels of both cytoplasmic and mitochondrial CPK genes. Moreover, atorvastatin does not increase the ATP amount or increase LDH activity. Remarkable, the nutraceutical composition is able to decrease CPK levels in serum of patients and in some cases improve myalgia symptoms. Conclusion: The nutraceutical composition decreases CPK levels both in vitro and in vivo, suggesting that it might be useful to management of nonneurological myalgia symptoms.

Evaluation of low-level laser therapy on skeletal muscle ischemia-reperfusion in streptozotocin-induced diabetic rats by assaying biochemical markers and histological changes.

The purpose of the present study was to assess the effects of low-level laser therapy (LLLT) on skeletal muscle ischemia-reperfusion (IR) injuries in streptozotocin-induced diabetic rats. Twenty male Wistar rats were randomly assigned into two experimental groups, as follows: the diabetic IR group (G1, n = 10) and the diabetic IR + LLLT group (G2, n = 10). Ischemia was induced in anesthetized rats from the right femoral artery clipping for 2h, followed by a reperfusion for 24h. Then, the laser irradiation (K30 handheld probe, AZOR, Technica, Russia, 650nm, 30mW, surface area = 1cm(2), energy density = 1.8J/cm(2)) was carried out by irradiating the rats over a unique point on the skin over the middle region of the right gastrocnemius muscle belly three times (every 8h), starting after initiating the reperfusion for 3min. At the end of the reperfusion period, rats were anaesthetized and blood samples were collected and used for the estimation of pO2, pCO2, pH, HCO3, serum creatine phosphokinase (CPK), and lactate dehydrogenase (LDH). Subsequently, the right gastrocnemius muscle samples were taken for wet/dry weight ratio assessment and histological/biochemical examination. The pO2, pCO2, HCO3, and pH levels were similar for both groups (P > 0.05). The serum LDH and CPK levels were significantly lower (P < 0.05) for G2 compared to G1. In comparison to G1, tissue malondialdehyde level in G2 was significantly decreased (P < 0.05). In G2, superoxide dismutase activity was significantly increased compared to G1 (P < 0.05). Unlike G2, a significant decrease in the activity of catalase was observed in G1 (P < 0.05). The wet/dry ratio in G1 was significantly higher than that of G2 (P < 0.05). Histological examination confirmed that the extent of muscle changes in G1 was higher than G2 (P < 0.05). Finally, according to this study, LLLT has a beneficial effect on the IR muscle injury treatment in the diabetic rats. Therefore, we suggest that further research needs to be conducted using different laser parameters and examining response over a longer period of tissue recovery.

Serum creatine phosphokinase levels as an indicator of muscle injury following lumbar disc surgery: Comparison of fully endoscopic discectomy and microdiscectomy

ObjectiveThe aim of this study is to make a comparison between fully endoscopic lumbar discectomy (FELD) and conventional microdiscectomy (MD) by using pre- and postoperative serum creatine phosphokinase (CPK) levels in correlation with postoperative low-back pain. MethodsFortyfive consecutive patients who underwent surgery for lumbar disc herniation were allocated into three groups with 15 patients on each: (1) FELD with interlaminar approach (IL), (2) FELD with transforaminal approach (TF), (3) Conventional MD. Serum CPK levels pre- and 1, 6, 12 and 24h postoperatively, patients’ body mass index (BMI), operation duration and hospital stays were recorded. The low-back pain pre- and postoperatively was assessed with the use of the 100mm visual analog scale (VAS) and the “Oswestry Disability Index” (ODI). ResultsThere were 16 female (35.5%) and 29 male (64.5%) patients with a mean age of 44.1 years. CPK levels at 6th, 12th and 24th hours postoperatively were found significantly lower in TF and IL groups compared to MD group (p<0.004). Mean operation duration was significantly shorter in MD group (p: 0.014). There was a significant decrease in both the VAS and ODI scores after the surgery in all patient groups (p<0.001). Postoperative VAS scores were found significantly higher in MD group (p: 0.04). ConclusionMinimal invasive nature of FELD procedures compared to the MD was substantiated by serum CPK levels in this study. To draw definitive conclusions regarding pain relief, larger patient samples should be evaluated, although postoperative VAS scores were found in favor of FELD.