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Li Z, Tian Z. Restoration of autophagy activity by dipsacoside B alleviates exhaustive exercise-induced kidney injury via the AMPK/mTOR pathway. Nat Prod Res 2024:1-7. [PMID: 38293762 DOI: 10.1080/14786419.2024.2308002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 01/16/2024] [Indexed: 02/01/2024]
Abstract
Exhaustive exercise (EE) induces kidney injury, but its concrete mechanism has not been fully elucidated. Hepatoprotective effects of dipsacoside B (DB) have been found previously, involving in autophagy induction. However, whether DB exerts renal protective effect and its potential mechanism are still unknown. The present study aimed to investigate the benefit of DB in EE-induced kidney injury and decipher its underlying mechanism. Here, we found that DB ameliorated EE-induced renal dysfunction and renal histopathological injury in rats. DB possessed anti-inflammatory, anti-oxidative, and anti-apoptotic functions in kidneys of exercise-induced exhausted rats. Besides, DB improved autophagy function in kidneys of EE rats. Mechanically, activation of the adenylate-activating protein kinase (AMPK)/mammalian target of rapamycin (mTOR) pathway was implicated in the kidney injury-relieving effects and autophagy restoration induced by DB. Collectively, these findings provide reference for the clinical application of DB in preventing and managing EE-induced kidney injury.
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Affiliation(s)
- Zhenyu Li
- Sias University, Xinzheng, P.R. China
- The 521 Laboratory of Sports Physiology and Biochemistry, Department of Sport Science, College of Natural Science, Jeonbuk National University, Jeonju-si, Republic of Korea
| | - Zhuang Tian
- The 521 Laboratory of Sports Physiology and Biochemistry, Department of Sport Science, College of Natural Science, Jeonbuk National University, Jeonju-si, Republic of Korea
- College of Physical Education, Zhengzhou University, Zhengzhou, P.R. China
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2
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Adnan Bukhari H. A Systematic Review on Outcomes of Patients with Heatstroke and Heat Exhaustion. Open Access Emerg Med 2023; 15:343-354. [PMID: 37771523 PMCID: PMC10522494 DOI: 10.2147/oaem.s419028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/30/2023] [Indexed: 09/30/2023] Open
Abstract
Introduction Heatstroke (HS) is a severe form of heat-related illness (HRI) associated with high morbidity and mortality, representing a condition that includes long-term multiorgan dysfunction and susceptibility to further heat illness. Methods In a systematic review searching Medline PubMed from the studies conducted between 2009 and 2020, 16 papers were identified. Results A hallmark symptom of heat stroke is CNS dysfunction (a hallmark sign of HS) which manifests as mental status changes, including agitation, delirium, epilepsy, or coma at the time of the collapse. Acute kidney injury (AKI), gut ischemia, blood clots in the stomach and small intestine, cytoplasmic protein clumps in the spleen, and injury of skeletal muscle (rhabdomyolysis) are all characteristics of peripheral tissue damage. Severe heat stroke tends to be complicated by rhabdomyolysis, especially in patients with exertional heat stroke. Rhabdomyolysis may lead to systemic effects, including the local occurrence of compartment syndrome, hyperkalemic cardiac arrest, and/or lethal disseminated intravascular coagulopathy. Untreated heat stroke might exacerbate psychosis, lactic acidosis, consumptive coagulopathy, hematuria, pulmonary edema, renal failure, and other metabolic abnormalities. Core body temperature and level of consciousness are the most significant indicators to diagnose the severity of heat stroke and prevent unfavorable consequences. Heatstroke is a life-threatening illness if not promptly recognized and effectively treated. Discussion This review highlighted that core body temperature and white blood cell count are significant contributing factors affecting heat stroke outcomes. Other factors contributing to the poor outcome include old age, low GCS, and prolonged hospital stay. The prevalence of both classic and exertional heatstroke can be reduced by certain simple preventive measures, such as avoiding strenuous activity in hot environments and reducing exposure to heat stress.
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3
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The effect of two types of diet on apoptosis indexes, lipid profile and histopathological outcome in acute kidney injury during exercise. BMC Nephrol 2022; 23:315. [PMID: 36123655 PMCID: PMC9487158 DOI: 10.1186/s12882-022-02938-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background Exercise and some pre-AKI diets have been shown to improve injury, apoptosis, and lipid profile. In this study, the effect of two different diets along with exercise training on acute kidney injury (AKI) was investigated. Materials and methods Laboratory rats were randomly divided into four groups of control, standard diet + exercise, exercise + calorie restriction (CR) and exercise + time restriction (TR). Each group was divided into two subgroups of AKI and no AKI. The animals received endurance training and diet regimens before AKI. Fasting blood glucose, serum creatinine, Bcl-2-associated X protein (Bax), B-cell lymphoma 2 (Bcl2) and histopathological outcome of renal tissue as well as serum lipid profile of animals were assessed 24 h after AKI. Results The percentage of changes in renal Bcl2 and Bax after AKI in the group with previous exercise was lower than the group without previous exercise (p < 0.01). After induction of AKI, serum lipid profile changed in non-exercised rats (p < 0.001). Also, after injury, fasting blood glucose levels increased in non-exercised rats (p < 0.05). After injury, the start of both CR and TR diets during exercise caused less change in Bcl2 and Bax of non-exercised rats compared to exercised rats (p < 0.001). CR diet along with exercise improved lipid profile, and also CR diet along exercise decreased fasting blood glucose levels (p < 0.001). Also, both the CR and TR diets during exercise caused fewer changes in histopathological outcome after AKI. Conclusion Exercise alone decreased changes in apoptotic and histopathological indexes, fasting blood glucose, as well as lipid profile of rats after AKI. Reduction of apoptosis and improvement of histopathological outcome after AKI appeared more when CR and TR diets were commenced during exercise. The reduction of lipid profile changes was more pronounced in the group that received CR diet during exercise.
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4
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Ko A, Song J, Golovko G, El Ayadi A, Ozhathil DK, Wermine K, Africa RE, Gotewal S, Reynolds S, Wolf SE. Higher risk of acute kidney injury and death with rhabdomyolysis in severely burned patients. Surgery 2022; 171:1412-1416. [PMID: 35078633 PMCID: PMC9241979 DOI: 10.1016/j.surg.2021.09.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Rhabdomyolysis is a severe condition responsible for up to 10% of acute kidney injury (AKI) cases. Severely burned patients are susceptible to developing both rhabdomyolysis and acute kidney injury, but whether burned patients with rhabdomyolysis are at greater risk of acute kidney injury compared to non-burned patients with rhabdomyolysis is unclear. METHODS TriNetX, a clinical research platform, was used to obtain electronic medical record information in 3 patient cohorts over the recent 20-year period. Cohort 1 included burn patients who developed rhabdomyolysis, cohort 2 were those who developed rhabdomyolysis due to non-burn causes, and cohort 3 included burn patients who did not develop rhabdomyolysis. Matching was performed to balance demographics and comorbidities for each cohort. Cohorts were then compared for the development of acute kidney injury and death. RESULTS We found 84 of 111 patients in cohort 1 (75.676%), 56 of 111 patients in cohort 2 (50.45%), and 18 of 111 patients in cohort 3 (16.216%) developed acute kidney injury within 5 days. The odds ratio for developing acute kidney injury for burned patients compared to non-burned patients with rhabdomyolysis was 3.056 with a 95% confidence interval of 1.726 to 5.41 (P < .05), and between burned patients with and without rhabdomyolysis was 16.074 with a 95% confidence interval of 8.263 to 31.268 (P < .05). The incidence of death within 1 year was also significantly higher in cohort 1 (48%) than the other cohorts (9% and 14%, respectively) (P < .05). CONCLUSION The risk of acute kidney injury and mortality in severely burned patients with rhabdomyolysis is significantly increased compared to matched non-burn patients with rhabdomyolysis or burned patients without rhabdomyolysis.
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Affiliation(s)
- Andrew Ko
- School of Medicine, University of Texas Medical Branch, Galveston, TX
| | - Juquan Song
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - George Golovko
- Department of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX
| | - Amina El Ayadi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Deepak K Ozhathil
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Kendall Wermine
- School of Medicine, University of Texas Medical Branch, Galveston, TX
| | - Robert E Africa
- School of Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sunny Gotewal
- School of Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sandy Reynolds
- Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX.
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5
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Tidmas V, Brazier J, Hawkins J, Forbes SC, Bottoms L, Farrington K. Nutritional and Non-Nutritional Strategies in Bodybuilding: Impact on Kidney Function. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074288. [PMID: 35409969 PMCID: PMC8998289 DOI: 10.3390/ijerph19074288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/23/2022] [Accepted: 03/29/2022] [Indexed: 12/10/2022]
Abstract
Bodybuilders routinely engage in many dietary and other practices purported to be harmful to kidney health. The development of acute kidney injury, focal segmental glomerular sclerosis (FSGS) and nephrocalcinosis may be particular risks. There is little evidence that high-protein diets and moderate creatine supplementation pose risks to individuals with normal kidney function though long-term high protein intake in those with underlying impairment of kidney function is inadvisable. The links between anabolic androgenic steroid use and FSGS are stronger, and there are undoubted dangers of nephrocalcinosis in those taking high doses of vitamins A, D and E. Dehydrating practices, including diuretic misuse, and NSAID use also carry potential risks. It is difficult to predict the effects of multiple practices carried out in concert. Investigations into subclinical kidney damage associated with these practices have rarely been undertaken. Future research is warranted to identify the clinical and subclinical harm associated with individual practices and combinations to enable appropriate and timely advice.
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Affiliation(s)
- Victoria Tidmas
- Centre for Research in Psychology and Sports Science, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (V.T.); (L.B.)
| | - Jon Brazier
- Centre for Research in Psychology and Sports Science, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (V.T.); (L.B.)
- Correspondence:
| | - Janine Hawkins
- Centre for Health Services and Clinical Research, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (J.H.); (K.F.)
| | - Scott C. Forbes
- Department of Physical Education Studies, Brandon University, Brandon, MB R7A 6A9, Canada;
| | - Lindsay Bottoms
- Centre for Research in Psychology and Sports Science, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (V.T.); (L.B.)
| | - Ken Farrington
- Centre for Health Services and Clinical Research, De Havilland Campus, University of Hertfordshire, Hatfield AL10 9EU, UK; (J.H.); (K.F.)
- Renal Unit, Lister Hospital, East and North Herts Trust, Stevenage SG1 4AB, UK
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6
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Schetz D, Sztormowska-Achranowicz K, Foerster J, Kocić I. Muscle pain and muscle weakness in COVID19 patients: Cross-talk with statins - Preliminary results. Biomed Pharmacother 2022; 148:112757. [PMID: 35231696 PMCID: PMC8866076 DOI: 10.1016/j.biopha.2022.112757] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/01/2022] Open
Abstract
Background Muscle pain and muscle weakness, common symptoms among statin-treated patients, may worsen with COVID-19 infection. Aims The aim of the paper was to find out if concomitant COVID-19 infections increase the frequency of specific side effects of statins such as muscle pain and muscle weakness. Method A total of 66 patients diagnosed with COVID-19 without comorbidities participated in the study. The patients were divided into two groups: statin-users who had not experienced adverse effects of statins in the past (statin group (SG)) and patients who had not used any drugs in the past six months (control group (CG)). The severity of muscle pain and creatinine kinase (CK) activity was evaluated in each patient, and muscle weakness was confirmed by a dynamometer test (grip strength on both hands). Results In SG, muscle pain was more common and it was characterized by a high level of intensity. Muscle weakness occurred more frequently in the SG and it was more frequent compared to CG. The CK parameter was observed to be higher in the SG compared to the CG and was often associated with the severity of muscle pain in the range of moderate to severe. Conclusions Our study indicates that COVID-19 is associated with the higher risk of occurrence of typical statin-related side effects, especially with more advanced age, which should be considered in future trials and treatments.
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Affiliation(s)
- Daria Schetz
- Department of Pharmacology, Faculty of Medicine, Medical University of Gdańsk, Poland.
| | | | - Jerzy Foerster
- Division of Social and Clinical Gerontology, Faculty of Health Sciences with the Institute of Maritime and Tropical Medicine, Medical University of Gdańsk, Poland
| | - Ivan Kocić
- Department of Pharmacology, Faculty of Medicine, Medical University of Gdańsk, Poland
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7
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Masuda Y, Wam R, Paik B, Ngoh C, Choong AM, Ng JJ. Clinical characteristics and outcomes of exertional rhabdomyolysis after indoor spinning: a systematic review. PHYSICIAN SPORTSMED 2022:1-12. [PMID: 35254210 DOI: 10.1080/00913847.2022.2049645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES An increasing number of patients are diagnosed with exertional rhabdomyolysis secondary to indoor spinning. We performed a systematic review to characterize the clinical features of this new clinical entity. METHODS We conducted a thorough literature search on PubMed, Embase, Web of Science, Scopus, and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles published from inception to 23 June 2021 were considered. A two-stage article selection process was performed. Articles that reported clinical characteristics and outcomes in patients with spin-induced exertional rhabdomyolysis (SIER) were included. Quality assessment was performed using the Joanna Briggs Institute checklists. RESULTS There were a total of 22 articles and 97 patients with SIER. Most patients were healthy females who had attended their first spinning session. The mean time to clinical presentation was 3.1 ± 1.5 days. The most common presenting symptoms were myalgia, dark urine, and muscle weakness in the thighs. Seven patients (7.2%) developed acute kidney injury, and two patients (2.1%) required temporary inpatient hemodialysis. Four patients (4.1%) developed thigh compartment syndrome and required fasciotomies. No long-term sequelae or mortality were observed. The mean length of stay was 5.6 ± 2.9 days. CONCLUSIONS Healthcare professionals must have a high index of suspicion for SIER when a patient presents with myalgia, dark urine, or weakness after a recent episode of indoor spinning. Fitness center owners, spinning instructors, and participants should also be better educated about the clinical features and manifestations of SIER.
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Affiliation(s)
- Yoshio Masuda
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rachel Wam
- Yale-NUS College, National University of Singapore, Singapore
| | - Benjamin Paik
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Clara Ngoh
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Mtl Choong
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Vascular and Endovascular Surgery, National University Heart Centre, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Jun Jie Ng
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Vascular and Endovascular Surgery, National University Heart Centre, Singapore
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8
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Tan B, Kon C, Loh S, Ng L, Lum V. Rhabdomyolysis Masquerading as Cauda Equina Syndrome. Cureus 2022; 14:e23048. [PMID: 35464562 PMCID: PMC9001814 DOI: 10.7759/cureus.23048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/05/2022] Open
Abstract
Lower back pain is a very common presenting condition, with a large proportion resulting from discogenic causes, especially after strenuous activity. In patients with a history of exertion, lower back pain, and acute urinary retention, the obvious diagnosis to exclude would be cauda equina syndrome. We present a case of a 32-year-old man who presented with lower back pain, bilateral lower limb weakness, and acute urinary retention following a recent episode of heavy lifting. He was subsequently diagnosed with rhabdomyolysis. This case highlights that rarer conditions can masquerade as cauda equina syndrome, and even in seemingly straightforward presentations, alternative diagnoses should also be considered.
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9
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Effect of Quercetin on Injury to Indomethacin-Treated Human Embryonic Kidney 293 Cells. Life (Basel) 2021; 11:life11111134. [PMID: 34833010 PMCID: PMC8623736 DOI: 10.3390/life11111134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 12/03/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat inflammation and pain and even to prevent the progression of cardiovascular disease. They have become widely used because of their effectiveness, especially among athletes performing high-intensity training. Indomethacin is used for pain management in sports medicine and is highly effective and versatile. However, several clinical studies have reported that indomethacin induces acute renal damage. In the present study, we determined that indomethacin reduced human embryonic kidney 293 (HEK293) cell viability in a concentration-dependent manner by triggering apoptosis. In addition, we demonstrated the effect of quercetin on indomethacin-treated HEK293 cells by inactivating the caspase-3 and caspase-9 signals. Furthermore, quercetin reduced ROS production and increased mitochondrial membrane potential (ΔΨm) in indomethacin-treated HEK293 cells. Our results indicate that quercetin can interrupt the activated caspase and mitochondrial pathway induced by indomethacin in HEK293 cells and affect apoptotic mRNA expression. Quercetin can protect against indomethacin-induced HEK293 cell apoptosis by regulating abnormal ΔΨm and apoptotic mRNA expression.
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10
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Electrolyte Beverage Intake to Promote Hydration and Maintain Kidney Function in Guatemalan Sugarcane Workers Laboring in Hot Conditions. J Occup Environ Med 2021; 62:e696-e703. [PMID: 33003044 PMCID: PMC7720870 DOI: 10.1097/jom.0000000000002033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To evaluate impact of electrolyte supplementation on hydration status and health outcomes in Guatemalan agricultural workers performing heavy work under hot climatic conditions. METHODS A 3-week pragmatic trial was conducted with a group of 50 workers during the 2017 to 2018 sugarcane harvest. Workers received an electrolyte hydration intervention during 2 of the 3 weeks. Blood and urine samples were collected each week. RESULTS Increased electrolyte intake resulted in less muscle injury. Kidney function was maintained across the intervention period. Workers were adequately hydrated and average electrolyte levels remained in normal ranges. Mild indications of hyponatremia occurred at higher levels of fluid intake. CONCLUSIONS This trial demonstrates the feasibility of maintaining workers' electrolyte levels under extremely hot and humid conditions while mitigating muscle injury. Electrolyte supplementation should be added to standard workplace water, rest, and shade interventions to protect workers.
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11
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Yow LPS, Ho HY, Lum IYW, Hanif IM. Exercise-Induced Rhabdomyolysis: A Case Series of Spin-Related Rhabdomyolysis. Cureus 2021; 13:e16352. [PMID: 34277311 PMCID: PMC8276198 DOI: 10.7759/cureus.16352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
Exercise rhabdomyolysis is a potentially life-threatening medical condition if not adequately managed early. With the increase in the popularity of indoor cycling, known as Spinning®, over recent years, there has been an increased occurrence of spin-related rhabdomyolysis observed among previously fit adults after undertaking their first spin bike class session. They present with the triad of myalgia, muscle weakness, and dark tea-colored urine within a week of their first spin session. This case series highlights several admissions to the hospital with spin-related rhabdomyolysis and their clinical management.
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Affiliation(s)
| | - Han Yao Ho
- Internal Medicine, Sengkang General Hospital, Singapore, SGP
| | | | - Ibrahim M Hanif
- Internal Medicine, Sengkang General Hospital, Singapore, SGP
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12
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Houser MC, Mac V, Smith DJ, Chicas RC, Xiuhtecutli N, Flocks JD, Elon L, Tansey MG, Sands JM, McCauley L, Hertzberg VS. Inflammation-Related Factors Identified as Biomarkers of Dehydration and Subsequent Acute Kidney Injury in Agricultural Workers. Biol Res Nurs 2021; 23:676-688. [PMID: 34018403 DOI: 10.1177/10998004211016070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Globally, there is increasing recognition that agricultural workers are at risk for chronic kidney disease of unknown etiology (CKDu). Recurrent heat exposure, physical exertion, dehydration, muscle damage, and inflammation are hypothesized to contribute to the development of CKDu, but the relative importance of these processes and the interactions among them remain unclear. Moreover, there is a need to identify biomarkers that could distinguish individuals who are at greatest risk for kidney damage to target preventative interventions for CKDu. In this study, we evaluated dehydration and markers of inflammation, muscle damage, and renal function in agricultural workers at a non-workday baseline assessment. Urine specific gravity and kidney function were measured before and after work shifts on three subsequent days, and heat index, core body temperature, and heart rate were monitored during the work shifts. A combination of direct comparisons and machine learning algorithms revealed that reduced levels of uromodulin and sodium in urine and increased levels of interleukin-6 and C-reactive protein in serum were indicative of dehydration at baseline, and that dehydration, high body mass index, reduced urine uromodulin, and increased serum interleukin-6, C-reactive protein, and lipopolysaccharide-binding protein at baseline were predictive of acute kidney injury on subsequent workdays. Our findings suggest a method for identifying agricultural workers at greatest risk for kidney injury and reveal potential mechanisms responsible for this process, including pathways overlapping in dehydration and kidney injury. These results will guide future studies confirming these mechanisms and introducing interventions to protect kidney health in this vulnerable population.
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Affiliation(s)
- Madelyn C Houser
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Valerie Mac
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Daniel J Smith
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Roxana C Chicas
- Renal Division, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Nezahualcoyotl Xiuhtecutli
- Farmworker Association of Florida, Apopka, FL, USA.,Department of Anthropology, Tulane University, New Orleans, LA, USA
| | - Joan D Flocks
- Social Policy Division, Center for Governmental Responsibility, Levin College of Law, University of Florida, Gainesville, FL, USA
| | - Lisa Elon
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, USA
| | | | - Jeff M Sands
- Renal Division, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Linda McCauley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Vicki S Hertzberg
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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13
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Carneiro A, Viana-Gomes D, Macedo-da-Silva J, Lima GHO, Mitri S, Alves SR, Kolliari-Turner A, Zanoteli E, Neto FRDA, Palmisano G, Pesquero JB, Moreira JC, Pereira MD. Risk factors and future directions for preventing and diagnosing exertional rhabdomyolysis. Neuromuscul Disord 2021; 31:583-595. [PMID: 34193371 DOI: 10.1016/j.nmd.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/19/2022]
Abstract
Exertional rhabdomyolysis may occur when an individual is subjected to strenuous physical exercise. It is occasionally associated with myoglobinuria (i.e. "cola-colored" urine) alongside muscle pain and weakness. The pathophysiology of exertional rhabdomyolysis involves striated muscle damage and the release of cellular components into extracellular fluid and bloodstream. This can cause acute renal failure, electrolyte abnormalities, arrhythmias and potentially death. Exertional rhabdomyolysis is observed in high-performance athletes who are subjected to intense, repetitive and/or prolonged exercise but is also observed in untrained individuals and highly trained or elite groups of military personnel. Several risk factors have been reported to increase the likelihood of the condition in athletes, including: viral infection, drug and alcohol abuse, exercise in intensely hot and humid environments, genetic polymorphisms (e.g. sickle cell trait and McArdle disease) and epigenetic modifications. This article reviews several of these risk factors and proposes screening protocols to identify individual susceptibility to exertional rhabdomyolysis as well as the relevance of proteomics for the evaluation of potential biomarkers of muscle damage.
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Affiliation(s)
- Andréia Carneiro
- Departamento de Bioquímica, Instituto de Química, Universidade Federal do Rio de Janeiro, Brazil; Departamento de Química, Diretoria de Sistemas de Armas da Marinha, Marinha do Brazil, Brazil; Departamento de Parasitologia, Universidade de São Paulo, Instituto de Ciencias Biomédicas, Brazil.
| | - Diego Viana-Gomes
- Departamento de Corridas, Universidade Federal do Rio de Janeiro, Escola de Educação Física, Brazil
| | - Janaina Macedo-da-Silva
- Departamento de Parasitologia, Universidade de São Paulo, Instituto de Ciencias Biomédicas, Brazil
| | - Giscard Humberto Oliveira Lima
- Departamento de Biofísica, Universidade Federal de São Paulo, Brazil; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Italy
| | - Simone Mitri
- Centro de Ecologia Humana e Saúde do Trabalhador, Fundação Oswaldo Cruz, Brazil
| | | | | | - Edmar Zanoteli
- Departamento de Neurologia, Faculdade de Medicina, Universidade de São Paulo, Brazil
| | | | - Giuseppe Palmisano
- Departamento de Parasitologia, Universidade de São Paulo, Instituto de Ciencias Biomédicas, Brazil
| | - João Bosco Pesquero
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Italy
| | | | - Marcos Dias Pereira
- Departamento de Bioquímica, Instituto de Química, Universidade Federal do Rio de Janeiro, Brazil.
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14
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The Potential Role of Exercise-Induced Muscle Damage in Exertional Heat Stroke. Sports Med 2021; 51:863-872. [PMID: 33528800 DOI: 10.1007/s40279-021-01427-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 01/06/2023]
Abstract
Exertional heat stroke (EHS) is a life-threatening condition that affects mainly athletes, military personnel, firefighters, and occupational workers. EHS is frequently observed in non-compensable conditions (where the body is unable to maintain a steady thermal balance) as a result of heavy heat stress and muscle contraction associated with prolonged and strenuous physical and occupational activities, resulting in central nervous system dysfunction followed by multi-organ damage and failure. Since the pathophysiology of EHS is complex and involves multiple organs and systems, any condition that changes the interrelated systems may increase the risk for EHS. It has been suggested that exercise-induced muscle damage (EIMD) can lead to thermoregulatory impairment and systemic inflammation, which could be a potential predisposing factor for EHS. In this review article, we aim to (1) address the evidence of EIMD as a predisposing factor for EHS and (2) propose a possible mechanism of how performing muscle-damaging exercise in the heat may aggravate muscle damage and subsequent risk of EHS and acute kidney injury (AKI). Such an understanding could be meaningful to minimize the risks of EHS and AKI for individuals with muscle damage due to engaging in physical work in hot environments.
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Association between collapse and serum creatinine and electrolyte concentrations in marathon runners: a 9-year retrospective study. Eur J Emerg Med 2021; 28:34-42. [PMID: 32976313 DOI: 10.1097/mej.0000000000000739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Abnormal biochemical measurements have previously been described in runners following marathons. The incidence of plasma sodium levels outside the normal range has been reported as 31%, and the incidence of raised creatinine at 30%. This study describes the changes seen in electrolytes and creatinine in collapsed (2010-2019 events) and noncollapsed (during the 2019 event) runners during a UK marathon. METHODS Point-of-care sodium, potassium, urea and creatinine estimates were obtained from any collapsed runner treated by the medical team during the Brighton Marathons, as part of their clinical care, and laboratory measurements from control subjects. RESULTS Results from 224 collapsed runners were available. Serum creatinine was greater than the normal range in 68.9%. About 6% of sodium results were below, and 3% above the normal range, with the lowest 132 mmol/l. Seventeen percent of potassium readings were above the normal range; the maximum result was 8.4 mmol/l, but 97% were below 6.0 mmol/l. In the control group, mean creatinine was significantly raised in both the collapse and control groups, with 55.4% meeting the criteria for acute kidney injury, but had resolved to baseline after 24 h. Sodium concentration but not the potassium was significantly raised after the race compared with baseline, but only 15% were outside the normal range. CONCLUSION In this study, incidence of a raised creatinine was higher than previously reported. However, the significance of such a rise remains unclear with a similar rise seen in collapsed and noncollapsed runners, and resolution noted within 24 h. Abnormal sodium concentrations were observed infrequently, and severely abnormal results were not seen, potentially reflecting current advice to drink enough fluid to quench thirst.
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Chung JJ, Cho ES, Choi JM, Yu JS. Retrospective Comparison of Renal Ultrasonographic and Clinical Findings in Patients with Rhabdomyolysis. J Med Ultrasound 2020; 28:151-155. [PMID: 33282658 PMCID: PMC7709536 DOI: 10.4103/jmu.jmu_95_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/02/2019] [Accepted: 12/10/2019] [Indexed: 11/28/2022] Open
Abstract
Background: This study evaluated the ultrasonographic and clinical findings of two groups with rhabdomyolysis, who showed abnormal or normal ultrasonographic findings of kidneys. Methods: Two groups (n = 78) of abnormal (A) and normal (B) renal ultrasonographic findings were included. Multiple laboratory findings were assessed within 2 days before or after ultrasonography. Student's t-test or Mann–Whitney U-test was used for statistical analysis. Results: The variable causes of rhabdomyolysis were intense exercise, burn, operation, shivering, and drug intoxication, etc. Group A (n = 26; M:F = 19:7) showed enlarged both kidneys, increased parenchymal thickness, and increased (n = 23, 88.5%) or decreased (n = 3, 11.5%) cortical echogenicity. Group A also showed elevated blood urea nitrogen (BUN), creatinine, potassium, and prolonged activated partial thromboplastin time (aPTT), compared with those in Group B (n = 52; M:F = 36:16), and these results were statistically significant (P < 0.01). The myoglobin in serum and urine, creatine kinase, prothrombin time, dark urine, and microscopic hematuria were not statistically different between the two groups. Conclusion: Patients with elevated BUN, creatinine, potassium, and prolonged aPTT showed the ultrasonographic findings of acute kidney injury, but other parameters were not statistically different between the two groups.
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Affiliation(s)
- Jae-Joon Chung
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Suk Cho
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Min Choi
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Sik Yu
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
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Longobardi NC, Longobardi Y. Recurrent Exercise-Induced Rhabdomyolysis in a Healthy Adolescent Girl. Cureus 2020; 12:e11462. [PMID: 33329960 PMCID: PMC7733763 DOI: 10.7759/cureus.11462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Female symptomatic carriers of Duchenne muscular dystrophy (DMD) are uncommon findings. Much of this disease has been studied from a male perspective, but female disease presentation and progression are rarely described. This report describes a female adolescent patient with a rare and unconventional presentation of DMD.
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Rojas-Valverde D, Sánchez-Ureña B, Crowe J, Timón R, Olcina GJ. Exertional rhabdomyolysis and acute kidney injury in endurance sports: A systematic review. Eur J Sport Sci 2020; 21:261-274. [PMID: 32202487 DOI: 10.1080/17461391.2020.1746837] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The increase of wide-spread participation in endurance events in sports such as open water swimming, cycling, running and triathlons, has given rise to a concern about potential implications for renal function and kidney health. This study aimed to delve into the findings on exertional rhabdomyolysis (ER) and acute kidney injury (AKI) in endurance sports, emphasizing the diagnostic criteria used, physical and environmental contextual conditions in which ER and AKI are reported. Following PRISMA guidelines for systematic reviews and meta-analysis, topic related studies were searched digital sources (from 2009 to 2020). Studies with biomarkers of ER and AKI reported in endurance or ultra-endurance events were included. A total of 43 publications (sample = 813) were extracted, and 345 (43.5%) individuals were diagnosed with ER (creatinine kinase > 5000 UI/L) and 130 (16.39%) with ER + AKI (creatinine ≥ 1.88 mg/dL). Out of the total cases of ER + AKI, 96.92% were in ultra-endurance runners. There were inconsistences between studies in diagnosis criteria for ER and AKI, which represented a difficulty in the interpretation of the data. Increased levels of muscle and kidney injury immediately after endurance events were reported, but after 5.86 days these levels usually returned to baseline. There is a lack of knowledge around the potential of repeated ER and AKI predisposing to long-term chronic kidney disease. More accurate markers for subclinical and functional AKI diagnosis are needed in the analysis of kidney health after endurance events. ER and AKI are serious clinical problems with significant morbidity. Further research may be in order to help define future prevention strategies.
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Affiliation(s)
- Daniel Rojas-Valverde
- Centro de Investigación y Diagnóstico en Salud y Deporte, Escuela Ciencias del Movimiento Humano y Calidad de Vida, Universidad Nacional, Heredia, Costa Rica.,Grupo Avances en Entrenamiento Deportivo y Acondicionamiento Físico (GAEDAF), Facultad Ciencias del Deporte, Universidad de Extremadura, Cáceres, Spain
| | - Braulio Sánchez-Ureña
- Programa de Ciencias del Ejercicio y la Salud, Escuela Ciencias del Movimiento Humano y Calidad de Vida, Universidad Nacional, Heredia, Costa Rica
| | - Jennifer Crowe
- Instituto Regional de Estudios Toxicológicos, Universidad Nacional, Heredia, Costa Rica
| | - Rafael Timón
- Grupo Avances en Entrenamiento Deportivo y Acondicionamiento Físico (GAEDAF), Facultad Ciencias del Deporte, Universidad de Extremadura, Cáceres, Spain
| | - Guillermo J Olcina
- Grupo Avances en Entrenamiento Deportivo y Acondicionamiento Físico (GAEDAF), Facultad Ciencias del Deporte, Universidad de Extremadura, Cáceres, Spain
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Moyce S, Armitage T, Mitchell D, Schenker M. Acute kidney injury and workload in a sample of California agricultural workers. Am J Ind Med 2020; 63:258-268. [PMID: 31773783 DOI: 10.1002/ajim.23076] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Kidney damage is associated with an increased workload in high ambient temperatures and may represent a pathway to chronic kidney disease of unknown origin in agricultural workers. We tested the associations of workload and heat with acute kidney dysfunction in California agricultural workers. METHODS We recruited a convenience sample of 471 agricultural workers from 29 farms in California during two summer harvest seasons. The sustained 3-minute maximum workload was estimated using accelerometer data collected from Actical monitors and individual heat load through elevations in core body temperature. Acute kidney injury (AKI) was defined by a change in serum creatinine of ≥0.3 mg/dL or ≥1.5 times the preshift creatinine over the course of the work shift. Associations between AKI and workload were modeled using logistic regression, controlling for demographic, physiologic, and occupational variables. RESULTS Of the total, 357 workers (75.8%) had accelerometer readings in the moderate workload category, 93 (19.7%) had readings in the vigorous category. 177 (36%) had elevations of core body temperature ≥1°C; 72 workers (14.9%) demonstrated evidence of AKI after a single day of agricultural work. The workload category was associated with an increased adjusted odds of AKI (1.92; 95% confidence interval, 1.05-3.51). Piece-rate work was also associated with increased adjusted odds of AKI (3.02; 95% CI, 1.44-6.34). CONCLUSIONS Heavy occupational workload and piece-rate work were associated with acute effects on the renal health of agricultural workers. This indicates that occupations requiring high physical effort put workers at risk for AKI, possibly independent of ambient and core body temperature. Changes to agricultural practices may reduce the risk of renal disorders for these workers.
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Affiliation(s)
- Sally Moyce
- College of Nursing, Montana State University, Bozeman, Montana
| | - Tracey Armitage
- Department of Public Health Sciences, University of California, Davis, Davis, California
| | - Diane Mitchell
- Department of Public Health Sciences, University of California, Davis, Davis, California
| | - Marc Schenker
- Department of Public Health Sciences, University of California, Davis, Davis, California
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Emerging Role of Ferroptosis in Acute Kidney Injury. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:8010614. [PMID: 31781351 PMCID: PMC6875218 DOI: 10.1155/2019/8010614] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/22/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022]
Abstract
Acute kidney injury (AKI) is a heterogeneous group of critical disease conditions with high incidence and mortality. Vasoconstriction, oxidative stress, apoptosis, and inflammation are generally thought to be the main pathogenic mechanisms of AKI. Ferroptosis is a type of iron-dependent nonapoptotic cell death characterized by membrane lipid peroxide accumulation and polyunsaturated fatty acid consumption, and it plays essential roles in many diseases, including cancers and neurologic diseases. Recent studies have revealed an emerging role of ferroptosis in the pathophysiological processes of AKI. Here, in the present review, we summarized the most recent discoveries on the role of ferroptosis in the pathogenesis of AKI as well as its therapeutic potential in AKI.
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Rates and treatments of CrossFit-related injuries at a single hospital system. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000766] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Arnautovic JZ, Tereziu S. Evaluation of Clinical Outcomes in Hospitalized Patients With Exertional Rhabdomyolysis. ACTA ACUST UNITED AC 2019; 119:428-434. [DOI: 10.7556/jaoa.2019.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Chlíbková D, Žákovská A, Rosemann T, Knechtle B, Bednář J. Body Composition Changes During a 24-h Winter Mountain Running Race Under Extremely Cold Conditions. Front Physiol 2019; 10:585. [PMID: 31139095 PMCID: PMC6527803 DOI: 10.3389/fphys.2019.00585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/26/2019] [Indexed: 12/20/2022] Open
Abstract
Background: To date, no study has focused on body composition characteristics and on parameters associated with skeletal muscle damage and renal function in runners participating in a 24-h winter race held under extremely cold environmental conditions (average temperature of -14.3°C). Methods: Anthropometric characteristics, plasma urea (PU), plasma creatinine (Pcr), creatine kinase (CK), plasma volume (PV) and total body water (TBW) were assessed pre- and post-race in 20 finishers (14 men and 6 women). Results: In male runners, body mass (BM) (p = 0.003) and body fat (BF) (p = 0.001) decreased [-1.1 kg (-1.4%) and -1.1 kg (-13.4%), respectively]; skeletal muscle mass (SM) and TBW remained stable (p > 0.05). In female runners, BF decreased (p = 0.036) [-1.3 kg (-7.8%)] while BM, SM and TBW remained stable (p > 0.05). The change (Δ) in BM was not related to Δ BF; however, Δ BM was related to Δ SM [r = 0.58, p = 0.007] and Δ TBW (r = 0.59, p = 0.007). Δ SM correlated with Δ TBW (r = 0.51, p = 0.021). Moreover, Δ BF was negatively associated with Δ SM (r = -0.65, p = 0.002). PV (p < 0.001), CK (p < 0.001), Pcr (p = 0.004) and PU (p < 0.001) increased and creatinine clearance (CrCl) decreased (p = 0.002). The decrease in BM was negatively related to the increase in CK (r = -0.71, p < 0.001). Δ Pcr was positively related to Δ PU (r = 0.64, p = 0.002). The decrease in CrCl was negatively associated with the increase in both PU (r = -0.72, p < 0.001) and CK (r = -0.48, p = 0.032). Conclusion: The 24-h running race under extremely cold conditions led to a significant BF decrease, whereas SM and TBW remained stable in both males and females. Nevertheless, the increase in CK, Pcr and PU was related to the damage of SM with transient impaired renal function.
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Affiliation(s)
- Daniela Chlíbková
- Centre of Sports Activities, Brno University of Technology, Brno, Czechia
| | - Alena Žákovská
- Institute of Experimental Biology, Masaryk University, Brno, Czechia
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Beat Knechtle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland.,Medbase St. Gallen Am Vadianplatz, St. Gallen, Switzerland
| | - Josef Bednář
- Institute of Mathematics, Brno University of Technology, Brno, Czechia
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Sorensen CJ, Butler-Dawson J, Dally M, Krisher L, Griffin BR, Johnson RJ, Lemery J, Asensio C, Tenney L, Newman LS. Risk Factors and Mechanisms Underlying Cross-Shift Decline in Kidney Function in Guatemalan Sugarcane Workers. J Occup Environ Med 2019; 61:239-250. [PMID: 30575695 PMCID: PMC6416034 DOI: 10.1097/jom.0000000000001529] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Identify early biomarkers and mechanisms of acute kidney injury in workers at risk of developing chronic kidney disease of unknown origin (CKDu). METHODS We assessed cross-shift changes in kidney function and biomarkers of injury in 105 healthy sugarcane workers. We obtained pre-harvest clinical data as well as daily environmental, clinical, and productivity data for each worker. RESULTS The average percent decline in cross-shift estimated glomerular filtration rate (eGFR) was 21.8% (standard deviation [SD] 13.6%). Increasing wet bulb globe temperature (WBGT), high uric acid, decreased urine pH, urinary leukocyte esterase, and serum hyperosmolality were risk factors for decline in kidney function. CONCLUSIONS Sugarcane workers with normal kidney function experience recurrent subclinical kidney injury, associated with elevations in biomarkers of injury that suggest exposure to high temperatures and extreme physical demands.
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Affiliation(s)
- Cecilia J Sorensen
- Center for Health, Work & Environment (Dr Sorensen, Dr Butler-Dawson, Ms Dally, Ms Krisher, Ms Tenney, Dr Newman); Department of Emergency Medicine, University of Colorado School of Medicine (Dr Sorensen, Dr Lemery); Colorado Consortium on Climate Change and Human Health (Dr Sorensen, Dr Butler-Dawson, Ms Dally, Ms Krisher, Dr Johnson, Dr Lemery, Ms Tenney, Dr Newman); Department of Environmental and Occupational Health (Dr Butler-Dawson, Ms Dally, Ms Krisher, Ms Tenney, Dr Newman), Colorado School of Public Health; Division of Renal Diseases and Hypertension (Dr Griffin, Dr Johnson); Pantaleon, Guatemala (Mr Asensio); Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, School of Medicine (Dr Newman), University of Colorado, Aurora, Colorado
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Hoffman MD. Predicted Risk for Exacerbation of Exercise-Associated Hyponatremia from Indiscriminate Postrace Intravenous Hydration of Ultramarathon Runners. J Emerg Med 2018; 56:177-184. [PMID: 30545731 DOI: 10.1016/j.jemermed.2018.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Asymptomatic or mildly symptomatic exercise-associated hyponatremia (EAH) can be exacerbated by aggressive hydration. OBJECTIVE This work predicts the percentage of athletes at risk for exacerbation of EAH from indiscriminate hydration after an ultramarathon. METHODS Postrace serum sodium, creatinine, creatine kinase (CK), and urea nitrogen concentrations were determined for 161-km ultramarathon participants. Body mass was measured prior to and immediately after the race. Incidents when serum CK was > 20,000 U/L or creatinine ≥ 1.5 times estimated baseline were considered to be "at risk for receiving I.V. hydration" if presenting to a hospital. Those with EAH without body mass loss during the race were considered "overhydrated" and "at risk for EAH exacerbation." RESULTS Among 627 finishers, 16 (2.6%) were at risk for EAH exacerbation. Considering 421 observations at risk for receiving I.V. hydration, 16 (47.1%) of the 34 observations with EAH were at risk for EAH exacerbation. Among those at risk for receiving I.V. hydration and with EAH, serum urea nitrogen and creatine concentration as a multiple of estimated baseline were lower (p < 0.05) for those at risk for EAH exacerbation, compared with those without overhydration, but there were no clinically useful laboratory findings to distinguish these two groups due to considerable overlap of values. CONCLUSIONS Whether in the field or hospital setting, I.V. hydration of an athlete after an ultramarathon carries a notable risk for exacerbating EAH, so clinicians should use caution when hydrating athletes after endurance events.
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Affiliation(s)
- Martin D Hoffman
- Physical Medicine & Rehabilitation Service, Department of Veterans Affairs, Northern California Health Care System, Sacramento, California; University of California Davis Medical Center, Sacramento, California; Ultra Sports Science Foundation, El Dorado Hills, California
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Leite MR, Zanetta DMT, Antonangelo L, Marçal LJ, Ramos D, Almeida Burdmann E, Paula Santos U. Burnt sugarcane harvesting work: effects on pulmonary and systemic inflammatory markers. Inhal Toxicol 2018; 30:205-212. [PMID: 30328727 DOI: 10.1080/08958378.2018.1494765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objective: To evaluate the effects of burnt sugarcane harvesting on the plasmatic and urinary concentrations of the club cell secretory protein (CC16) and inflammatory systemic biomarkers in a group of sugarcane cutters. Methods: Seventy-eight sugar cane workers were evaluated. The plasmatic and urinary concentrations of CC16, a pulmonary damage marker and inflammatory systemic biomarkers were collected at three time points: before, three months after and six months after the onset of the burnt sugarcane harvesting period. All evaluations were performed at ∼7 am, before the daily work shift. In the three-month evaluation, a post-work shift assessment (acute effect) was also performed. Results: The age of the workers was 37.9 ± 11.0 years. The PM2.5 concentrations were 27.0 (23.0-33.0) and 101.0 (31.0-139.5) µg/m3 in the pre harvest and harvest periods, respectively (p < .001). Burnt sugarcane harvesting was associated with a reduction, throughout the work during burnt sugarcane harvesting (subchronic effect), in plasmatic and urinary CC16 concentrations. Acutely, there was a decrease in plasmatic concentrations. There were acute and subchronic increases in inflammatory markers (neutrophils, monocytes) and muscle damage markers (CK and LDH) and a decrease in red blood cells. Conclusions: Harvesting of burnt sugarcane was associated with acute and subchronic reductions in the plasmatic and urinary concentrations of CC16 protein and changes in systemic inflammatory markers.
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Affiliation(s)
- Marceli Rocha Leite
- a Divisao de Pneumologia , Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo , São Paulo , Brazil
| | | | - Leila Antonangelo
- c Laboratório de Investigação Médica 03 (LIM-03) - Departamento de Patologia, da Faculdade de Medicina FMUSP , Universidade de São Paulo , São Paulo , Brazil
| | - Lia Junqueira Marçal
- c Laboratório de Investigação Médica 03 (LIM-03) - Departamento de Patologia, da Faculdade de Medicina FMUSP , Universidade de São Paulo , São Paulo , Brazil
| | - Dionei Ramos
- d Department of Physiotherapy , Universidade Estadual Paulista "Júlio de Mesquita Filho" Campus de Presidente Prudente , São Paulo , Brazil
| | - Emmanuel Almeida Burdmann
- e Laboratório de Investigação Médica 12 (LIM-12), Divisão de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina , Universidade de São Paulo , São Paulo , Brazil
| | - Ubiratan Paula Santos
- f Divisão de Pneumologia , Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo , São Paulo , Brazil
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Novel Factors Associated With Analgesic and Anti-inflammatory Medication Use in Distance Runners: Pre-race Screening Among 76 654 Race Entrants-SAFER Study VI. Clin J Sport Med 2018; 28:427-434. [PMID: 29944515 DOI: 10.1097/jsm.0000000000000619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Analgesic/anti-inflammatory medication (AAIM) increases the risk of medical complications during endurance races. We determined how many runners use AAIM before or during races, AAIM types, and factors associated with AAIM use. DESIGN Cross-sectional study. SETTING 21.1-km and 56-km races. PARTICIPANTS Seventy-six thousand six hundred fifty-four race entrants. METHODS Participants completed pre-race medical screening questions on AAIM use, running injury or exercise-associated muscle cramping (EAMC) history, and general medical history. MAIN OUTCOME MEASURES Analgesic/anti-inflammatory medication use, types of AAIM (% runners; 95% confidence interval), and factors associated with AAIM use (sex, age, race distance, history of running injury or EAMC, and history of chronic diseases) [prevalence ratio (PR)]. RESULTS Overall, 12.2% (12.0-12.5) runners used AAIM 1 week before and/or during races (56 km = 18.6%; 18.0-19.1, 21.1 km = 8.3%; 8.1-8.6) (P < 0.0001). During races, nonsteroidal anti-inflammatory drugs (NSAIDs) (5.3%; 5.1-5.5) and paracetamol (2.6%; 2.4-2.7) were used mostly. Independent factors (adjusted PR for sex, age, and race distance; P < 0.0001) associated with AAIM use were running injury (2.7; 2.6-2.9), EAMC (2.0; 1.9-2.1), cardiovascular disease (CVD) symptoms (2.1; 1.8-2.4), known CVD (1.7; 1.5-1.9), CVD risk factors (1.6; 1.5-1.6), allergies (1.6; 1.5-1.7), cancer (1.3; 1.1-1.5), and respiratory (1.7; 1.6-1.8), gastrointestinal (2.0; 1.9-2.2), nervous system (1.9; 1.7-2.1), kidney/bladder (1.8; 1.6-2.0), endocrine (1.5; 1.4-1.7), and hematological/immune (1.5; 1.2-1.8) diseases. CONCLUSIONS 12.2% runners use AAIM before and/or during races, mostly NSAIDs. Factors (independent of sex, age, and race distance) associated with AAIM use were history of injuries, EAMC, and numerous chronic diseases. We suggest a pre-race screening and educational program to reduce AAIM use in endurance athletes to promote safer races.
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Rhabdomyolysis in a patient complicated with hypopituitarism and multiple organ dysfunction syndrome and the literature review. Am J Emerg Med 2018; 36:1723.e1-1723.e6. [PMID: 29910183 DOI: 10.1016/j.ajem.2018.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 06/06/2018] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Muscular symptoms, including stiffness, myalgia, cramps, and fatigue, are present in the majority of the patients with hypopituitarism, adrenal insufficiency and hypothyroidism, but rhabdomyolysis, the rapid breakdown of skeletal muscle, is a rare manifestation. In most patients who develop rhabdomyolysis, precipitating factors, such as strenuous exercise or use of lipid-lowering drugs, can be identified. CASE REPORT We report the case of a 23-year-old male with primary hypopituitarism who developed acute renal impairment (AKI) with rhabdomyolysis after strenuous physical activity (push-ups). His blood test confirmed marked hypopituitarism. Severe elevation of serum CK consistent with rhabdomyolysis was noted and an elevated creatinine indicated AKI and multiple organ dysfunction syndrome (MODS). Patient's condition improved significantly after continuous renal replacement therapy (CRRT), glucocorticoid hormone replacement therapy and aggressive hydration. MODS with rhabdomyolysis in patients with hypothyroidism is quite rare and we expect that this case report adds to the existing literature on this subject. We also emphasize that thyroid and adrenal gland status should be evaluated in patients with unexplained AKI, MODS and presenting with the symptoms of muscle involvement. LITERATURE REVIEW We respectively reviewed 23 patients with hypopituitarism, adrenal Insufficiency and hypothyroidism induced rhabdomyolysis who were involved in the past 40 years relevant literatures. CONCLUSION We report a successfully treated case of rhabdomyolysis, which is a rare but potentially serious complication of hypopituitarism. Screening for endocrine abnormality in patients with elevated muscle enzymes should be considered, since an early diagnosis and prompt treatment is essential to prevent rhabdomyolysis and its consequences.
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Au-Yeung KL, Lam CC, Tsui SH. Three Cases of Exercise-Induced Rhabdomyolysis: A Potential Hazard in University Students Participating in Orientation Programs. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Most students entering universities will participate in the orientation programs organised by the universities, residential halls and departments. Many of these programs involve strenuous exercises and yet not being closely supervised by recognised physical trainers. Some students are not accustomed to heavy exercises. Still they may have to complete such tasks under peer pressure and sometimes in adverse environmental conditions. This makes them prone to develop exercise-induced/exertional rhabdomyolysis (ER). The hallmark symptoms of rhabdomyolysis are non-specific. As a result, it is often under-diagnosed. We described three cases of exercise-induced rhabdomyolysis in college students diagnosed in the accident and emergency department. All cases were managed successfully with supportive care in emergency medicine ward though the initial creatine kinase levels were alarming. (Hong Kong j.emerg.med. 2011;18:437-440)
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Fardal H, Gøransson LG. [Exercise-induced rhabdomyolysis - a new trend?]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:1537-1541. [PMID: 27731597 DOI: 10.4045/tidsskr.16.0042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether or not there has been an increase in the number of admissions for exercise-induced rhabdomyolysis at Stavanger University Hospital (SUS) in recent years. MATERIAL AND METHOD The study is a retrospective review of patients discharged over the period January 2010 to March 2015 with a diagnosis of exercise-induced rhabdomyolysis and with maximum creatine kinase (CK) levels more than ten times the upper reference limit. RESULTS A total of 33 patients, 21 women and 12 men, with a median age of 28 years (18 - 68), were included in the study. Of the 33 patients, three quarters (25) were admitted in 2014 - 15, compared with eight over the period 2010 - 13. One patient developed kidney failure that required dialysis. The treatment depended more on the attending physician and department than on the patient's clinical condition and CK-level, but this did not seem to affect the rate of complications. INTERPRETATION The incidence of exercise-induced rhabdomyolysis at SUS increased from autumn 2014, and this coincided with increased media attention and a new exercise trend. We recommend standardising the treatment of exercise-induced rhabdomyolysis, as current treatment recommendations are based on rhabdomyolysis triggered by causes other than exercise.
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Management of Severe Rhabdomyolysis and Exercise-Associated Hyponatremia in a Female with Anorexia Nervosa and Excessive Compulsive Exercising. Case Rep Med 2016; 2016:8194160. [PMID: 27721832 PMCID: PMC5046051 DOI: 10.1155/2016/8194160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/10/2016] [Accepted: 08/23/2016] [Indexed: 12/03/2022] Open
Abstract
This case report describes the management of a 49-year-old female with restricting-type anorexia nervosa and excessive compulsive exercising associated with rhabdomyolysis, high levels of serum creatine kinase (CK) (3,238 U/L), and marked hyponatremia (Na+: 123 mEq/L) in the absence of purging behaviours or psychogenic polydipsia; it is the first case report to describe exercise-associated hyponatremia in a patient with anorexia nervosa. The patient, who presented with a body mass index (BMI) of 13.4 kg/m2, was successfully treated by means of an adapted inpatient version of an enhanced form of cognitive behavioural therapy (CBT-E). Within a few days, careful water restriction, solute refeeding, and the specific cognitive behavioural strategies and procedures used to address the patient's excessive compulsive exercising and undereating produced a marked reduction in CK levels, which normalised within one week. Exercise-associated hyponatremia also gradually improved, with serum sodium levels returning to normal within two weeks. The patient thereby avoided severe complications such as cerebral or pulmonary oedema or acute renal failure and was discharged after 20 weeks of treatment with a BMI of 19.0 kg/m2 and improved eating disorder psychopathology.
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Kim J, Lee J, Kim S, Ryu HY, Cha KS, Sung DJ. Exercise-induced rhabdomyolysis mechanisms and prevention: A literature review. JOURNAL OF SPORT AND HEALTH SCIENCE 2016; 5:324-333. [PMID: 30356493 PMCID: PMC6188610 DOI: 10.1016/j.jshs.2015.01.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 10/26/2014] [Accepted: 01/26/2015] [Indexed: 05/27/2023]
Abstract
Exercise-induced rhabdomyolysis (exRML), a pathophysiological condition of skeletal muscle cell damage that may cause acute renal failure and in some cases death. Increased Ca2+ level in cells along with functional degradation of cell signaling system and cell matrix have been suggested as the major pathological mechanisms associated with exRML. The onset of exRML may be exhibited in athletes as well as in general population. Previous studies have reported that possible causes of exRML were associated with excessive eccentric contractions in high temperature, abnormal electrolytes balance, and nutritional deficiencies possible genetic defects. However, the underlying mechanisms of exRML have not been clearly established among health professionals or sports medicine personnel. Therefore, we reviewed the possible mechanisms and correlated prevention of exRML, while providing useful and practical information for the athlete and general exercising population.
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Affiliation(s)
- Jooyoung Kim
- Health and Rehabilitation Major, College of Physical Education, Kookmin University, Seoul 136-702, Republic of Korea
| | - Joohyung Lee
- Health and Rehabilitation Major, College of Physical Education, Kookmin University, Seoul 136-702, Republic of Korea
| | - Sojung Kim
- Department of Physical Education, Global Campus, Kyung Hee University, Suwon 446-701, Republic of Korea
| | - Ho Young Ryu
- Division of Sport Science, College of Science and Technology, Konkuk University, Choong-Ju 380-702, Republic of Korea
| | - Kwang Suk Cha
- Division of Sport Science, College of Science and Technology, Konkuk University, Choong-Ju 380-702, Republic of Korea
| | - Dong Jun Sung
- Division of Sport Science, College of Science and Technology, Konkuk University, Choong-Ju 380-702, Republic of Korea
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Sedgwick PE, Wortley GC, Wright JM, Asplund C, William OR, Usman S. Medical Clearance for Desert and Land Sports, Adventure, and Endurance Events. Wilderness Environ Med 2016; 26:S47-54. [PMID: 26617378 DOI: 10.1016/j.wem.2015.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/12/2015] [Indexed: 11/15/2022]
Abstract
Endurance events are increasing in popularity in wilderness and remote settings, and participants face a unique set of potential risks for participation. The purpose of this article is to outline these risks and allow the practitioner to better guide the wilderness adventurer who is anticipating traveling to a remote or desert environment.
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Affiliation(s)
- Peter E Sedgwick
- Central Maine Sports Medicine (A Clinical Division of CMMC), Lewiston, Maine (Dr Sedgwick).
| | - George C Wortley
- Lynchburg Family Medicine Residency, Lynchburg, Virginia (Dr Wortley)
| | - Justin M Wright
- Department of Family and Community Medicine, Paul L. Foster School of Medicine, El Paso, Texas (Dr Wright)
| | - Chad Asplund
- Family Medicine, Georgia Regents University, Augusta, Georgia (Dr Asplund)
| | - O Roberts William
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, Minnesota (Dr Roberts)
| | - Saif Usman
- Primary Care Sports Medicine, Marymount University, MedStar Medical Group, Arlington, Virginia (Dr Usman)
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Ryu H, Kim HS, Choi H, Kim J, Sung DJ. Rhabdomyolysis from spinning exercise and ephedra-contained herbal medicine. JOURNAL OF SPORT AND HEALTH SCIENCE 2016; 5:248-249. [PMID: 30356563 PMCID: PMC6188734 DOI: 10.1016/j.jshs.2015.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 06/30/2015] [Indexed: 06/08/2023]
Affiliation(s)
- Hoyoung Ryu
- Division of Sport Science, College of Science and Technology, Konkuk University, Chungju-si 380-701, Republic of Korea
| | - Hong Sup Kim
- Department of Urology, Konkuk University Hospital, Chungju-si 380-704, Republic of Korea
| | - Heejung Choi
- Department of Nephrology, Konkuk University Hospital, Chungju-si 380-704, Republic of Korea
| | - Jooyoung Kim
- Health and Rehabilitation Major, Kookmin University, Seoul 136-702, Republic of Korea
| | - Dong Jun Sung
- Division of Sport Science, College of Science and Technology, Konkuk University, Chungju-si 380-701, Republic of Korea
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Abstract
OBJECTIVE To outline a 4-phase progressive program that safely and successfully enabled athletes to return to sport without recurrence of exertional rhabdomyolysis symptoms. BACKGROUND In January 2011, a large cluster of National Collegiate Athletic Association Division I football athletes were evaluated and treated for exertional rhabdomyolysis. After the athletes were treated, the athletic trainers and sports medicine providers were challenged to develop a safe return-to-play program because of the lack of specific reports in the medical literature to direct such activities. TREATMENT A progressive 4-phase program based on existing recommendations, including guidelines for continued clinical and laboratory monitoring. CONCLUSIONS Although the actual process of reintegrating players will differ based on each athlete's unique circumstances, this program provides a safe and effective foundation that can be modified based on the response to activity and sport.
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Bodin T, García-Trabanino R, Weiss I, Jarquín E, Glaser J, Jakobsson K, Lucas RAI, Wesseling C, Hogstedt C, Wegman DH. Intervention to reduce heat stress and improve efficiency among sugarcane workers in El Salvador: Phase 1. Occup Environ Med 2016; 73:409-16. [PMID: 27073211 PMCID: PMC4893112 DOI: 10.1136/oemed-2016-103555] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/24/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic heat stress and dehydration from strenuous work in hot environments is considered an essential component of the epidemic of chronic kidney disease in Central America. OBJECTIVE (1) To assess feasibility of providing an intervention modelled on OSHA's Water.Rest.Shade programme (WRS) during sugarcane cutting and (2) to prevent heat stress and dehydration without decreasing productivity. METHODS Midway through the 6-month harvest, the intervention introduced WRS practices. A 60-person cutting group was provided water supplied in individual backpacks, mobile shaded rest areas and scheduled rest periods. Ergonomically improved machetes and efficiency strategies were also implemented. Health data (anthropometric, blood, urine, questionnaires) were collected preharvest, preintervention, mid-intervention and at the end of harvest. A subsample participated in focus group discussions. Daily wet bulb globe temperatures (WBGT) were recorded. The employer provided individual production records. RESULTS Over the harvest WBGT was >26°C from 9:00 onwards reaching average maximum of 29.3±1.7°C, around 13:00. Postintervention self-reported water consumption increased 25%. Symptoms associated with heat stress and with dehydration decreased. Individual daily production increased from 5.1 to a high of 7.3 tons/person/day postintervention. This increase was greater than in other cutting groups at the company. Focus groups reported a positive perception of components of the WRS, and the new machete and cutting programmes. CONCLUSIONS A WRS intervention is feasible in sugarcane fields, and appears to markedly reduce the impact of the heat stress conditions for the workforce. With proper attention to work practices, production can be maintained with less impact on worker health.
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Affiliation(s)
- T Bodin
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - R García-Trabanino
- Association of Nephrology and Hypertension of El Salvador, San Salvador, El Salvador
| | - I Weiss
- La Isla Foundation, Ada, Michigan, USA
| | - E Jarquín
- Agency for Development and Agricultural Health (AGDYSA), San Salvador, El Salvador
| | - J Glaser
- La Isla Foundation, Ada, Michigan, USA
| | - K Jakobsson
- Department of Public Health and Community Medicine, Gothenburg University, Gothenburg, Sweden
| | - R A I Lucas
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - C Wesseling
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - C Hogstedt
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - D H Wegman
- Department of Work Environment, University of Massachusetts Lowell, Lowell, Massachusetts, USA
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Abstract
Heat stroke is a life-threatening condition clinically diagnosed as a severe elevation in body temperature with central nervous system dysfunction that often includes combativeness, delirium, seizures, and coma. Classic heat stroke primarily occurs in immunocompromised individuals during annual heat waves. Exertional heat stroke is observed in young fit individuals performing strenuous physical activity in hot or temperature environments. Long-term consequences of heat stroke are thought to be due to a systemic inflammatory response syndrome. This article provides a comprehensive review of recent advances in the identification of risk factors that predispose to heat stroke, the role of endotoxin and cytokines in mediation of multi-organ damage, the incidence of hypothermia and fever during heat stroke recovery, clinical biomarkers of organ damage severity, and protective cooling strategies. Risk factors include environmental factors, medications, drug use, compromised health status, and genetic conditions. The role of endotoxin and cytokines is discussed in the framework of research conducted over 30 years ago that requires reassessment to more clearly identify the role of these factors in the systemic inflammatory response syndrome. We challenge the notion that hypothalamic damage is responsible for thermoregulatory disturbances during heat stroke recovery and highlight recent advances in our understanding of the regulated nature of these responses. The need for more sensitive clinical biomarkers of organ damage is examined. Conventional and emerging cooling methods are discussed with reference to protection against peripheral organ damage and selective brain cooling.
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Affiliation(s)
- Lisa R Leon
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Abderrezak Bouchama
- King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Experimental Medicine Department-King Abdulaziz Medical City-Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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[(Very) high Creatinkinase concentration after exertional whole-body electromyostimulation application: health risks and longitudinal adaptations]. Wien Med Wochenschr 2015; 165:427-35. [PMID: 26498468 DOI: 10.1007/s10354-015-0394-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 09/24/2015] [Accepted: 10/01/2015] [Indexed: 01/04/2023]
Abstract
Due to its individualization, time-efficiency and effectiveness Whole-body-Electromyo-stimulation (WB-EMS) becomes increasingly popular. However, recently (very) high Creatin-kinase concentration were reported, at least after initial WB-EMS-application. Thus, the aim of the study was to determine (1) WB-EMS induced increases of CK-concentration, (2) their impact on corresponding health parameters and (3) training-induced changes of CK-levels.Twenty-six healthy, sportive volunteers without previous experience with WB-EMS were included. Initial high intense WB-EMS application (bipolar, 85 Hz; 350 ms; intermittent, 20 min) led to an increase of the CK-level by the 117fold (28.545 ± 33.611 IU/l) of baseline. CK-peaks were detected after 72-96 h. Despite this pronounced "exertional rhabdomyolysis", we did not determine rhabdomyolysis-induced complications (e.g. acute renal failure, hyperkalemia, hypocalcaemia). After 10 weeks of WB-EMS (1 session/week) CK-reaction to intensive WB-EMS-Application was significantly blunted (906 ± 500 IE/l) and averaged in the area of conventional resistance exercise.In summary, intensity of WB-EMS should be carefully increased during the initial sessions.
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Abstract
Endurance events are increasing in popularity in wilderness and remote settings, and participants face a unique set of potential risks for participation. The purpose of this article is to outline these risks and allow the practitioner to better guide the wilderness adventurer who is anticipating traveling to a remote or desert environment.
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Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med 2015; 25:S30-42. [PMID: 25498260 DOI: 10.1016/j.wem.2014.08.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
Exercise-associated hyponatremia (EAH) is defined by a serum or plasma sodium concentration below the normal reference range of 135 mmol/L that occurs during or up to 24 hours after prolonged physical activity. It is reported to occur in individual physical activities or during organized endurance events conducted in austere environments in which medical care is limited and often not available, and patient evacuation to definitive care is often greatly delayed. Rapid recognition and appropriate treatment are essential in the severe form to ensure a positive outcome. Failure in this regard is a recognized cause of event-related fatality. In an effort to produce best practice guidelines for EAH in the austere environment, the Wilderness Medical Society convened an expert panel. The panel was charged with the development of evidence-based guidelines for management of EAH. Recommendations are made regarding the situations when sodium concentration can be assessed in the field and when these values are not known. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks/burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for Treatment of Exercise-Associated Hyponatremia published in Wilderness & Environmental Medicine 2013;24(3):228-240.
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Affiliation(s)
- Brad L Bennett
- Military & Emergency Medicine Department, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD (Dr Bennett).
| | | | - Martin D Hoffman
- Department of Physical Medicine & Rehabilitation, Department of Veterans Affairs, Northern California Health Care System, and University of California Davis Medical Center, Sacramento, CA (Dr Hoffman)
| | - Ian R Rogers
- St. John of God Murdoch Hospital & University of Notre Dame, Murdoch, Western Australia (Dr Rogers)
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia, Charlottesville, VA (Dr Rosner)
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Hou SK, Chiu YH, Tsai YF, Tai LC, Hou PC, How CK, Yang CC, Kao WF. Clinical Impact of Speed Variability to Identify Ultramarathon Runners at Risk for Acute Kidney Injury. PLoS One 2015; 10:e0133146. [PMID: 26176768 PMCID: PMC4503592 DOI: 10.1371/journal.pone.0133146] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/23/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Ultramarathon is a high endurance exercise associated with a wide range of exercise-related problems, such as acute kidney injury (AKI). Early recognition of individuals at risk of AKI during ultramarathon event is critical for implementing preventative strategies. OBJECTIVES To investigate the impact of speed variability to identify the exercise-related acute kidney injury anticipatively in ultramarathon event. METHODS This is a prospective, observational study using data from a 100 km ultramarathon in Taipei, Taiwan. The distance of entire ultramarathon race was divided into 10 splits. The mean and variability of speed, which was determined by the coefficient of variation (CV) in each 10 km-split (25 laps of 400 m oval track) were calculated for enrolled runners. Baseline characteristics and biochemical data were collected completely 1 week before, immediately post-race, and one day after race. The main outcome was the development of AKI, defined as Stage II or III according to the Acute Kidney Injury Network (AKIN) criteria. Multivariate analysis was performed to determine the independent association between variables and AKI development. RESULTS 26 ultramarathon runners were analyzed in the study. The overall incidence of AKI (in all Stages) was 84.6% (22 in 26 runners). Among these 22 runners, 18 runners were determined as Stage I, 4 runners (15.4%) were determined as Stage II, and none was in Stage III. The covariates of BMI (25.22 ± 2.02 vs. 22.55 ± 1.96, p = 0.02), uric acid (6.88 ± 1.47 vs. 5.62 ± 0.86, p = 0.024), and CV of speed in specific 10-km splits (from secondary 10 km-split (10th - 20th km-split) to 60th - 70th km-split) were significantly different between runners with or without AKI (Stage II) in univariate analysis and showed discrimination ability in ROC curve. In the following multivariate analysis, only CV of speed in 40th - 50th km-split continued to show a significant association to the development of AKI (Stage II) (p = 0.032). CONCLUSIONS The development of exercise-related AKI was not infrequent in the ultramarathon runners. Because not all runners can routinely receive laboratory studies after race, variability of running speed (CV of speed) may offer a timely and efficient tool to identify AKI early during the competition, and used as a surrogate screening tool, at-risk runners can be identified and enrolled into prevention trials, such as adequate fluid management and avoidance of further NSAID use.
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Affiliation(s)
- Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Yu-Hui Chiu
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yi-Fang Tsai
- Department of General Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ling-Chen Tai
- Department of General Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Peter C. Hou
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Chorng-Kuang How
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Chang Yang
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Fong Kao
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Institute of Environmental and Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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Chlíbková D, Knechtle B, Rosemann T, Tomášková I, Novotný J, Žákovská A, Uher T. Rhabdomyolysis and exercise-associated hyponatremia in ultra-bikers and ultra-runners. J Int Soc Sports Nutr 2015; 12:29. [PMID: 26113805 PMCID: PMC4480906 DOI: 10.1186/s12970-015-0091-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 06/17/2015] [Indexed: 01/06/2023] Open
Abstract
Background Exercise-associated hyponatremia (EAH), rhabdomyolysis and renal failure appear to be a unique problem in ultra-endurance racers. Methods We investigated the combined occurrence of EAH and rhabdomyolysis in seven different ultra-endurance races and disciplines (i.e. multi-stage mountain biking, 24-h mountain biking, 24-h ultra-running and 100-km ultra-running). Results Two (15.4 %) ultra-runners (man and woman) from hyponatremic ultra-athletes (n = 13) and four (4 %) ultra-runners (four men) from the normonatremic group (n = 100) showed rhabdomyolysis following elevated blood creatine kinase (CK) levels > 10,000 U/L without the development of renal failure and the necessity of a medical treatment. Post-race creatine kinase, plasma and urine creatinine significantly increased, while plasma [Na+] and creatine clearance decreased in hyponatremic and normonatremic athletes, respectively. The percentage increase of CK was higher in the hyponatremic compared to the normonatremic group (P < 0.05). Post-race CK levels were higher in ultra-runners compared to mountain bikers (P < 0.01), in faster normonatremic (P < 0.05) and older and more experienced hyponatremic ultra-athletes (P < 0.05). In all finishers, pre-race plasma [K+] was related to post-race CK (P < 0.05). Conclusions Hyponatremic ultra-athletes tended to develop exercise-induced rhabdomyolysis more frequently than normonatremic ultra-athletes. Ultra-runners tended to develop rhabdomyolysis more frequently than mountain bikers. We found no association between post-race plasma [Na+] and CK concentration in both hypo- and normonatremic ultra-athletes.
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Affiliation(s)
- Daniela Chlíbková
- Centre of Sports Activities, Brno University of Technology, Brno, Czech Republic
| | - Beat Knechtle
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Ivana Tomášková
- Faculty of Forestry and Wood Sciences, Czech University of Life Sciences, Prague, Czech Republic
| | - Jan Novotný
- Faculty of Sports Studies, Masaryk University, Brno, Czech Republic
| | - Alena Žákovská
- Institute of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Tomáš Uher
- Center for Adult Medicine in Bohunice, University Hospital Brno, Brno, Czech Republic
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Sanchis-Gomar F, Pareja-Galeano H, Perez-Quilis C, Santos-Lozano A, Fiuza-Luces C, Garatachea N, Lippi G, Lucia A. Effects of allopurinol on exercise-induced muscle damage: new therapeutic approaches? Cell Stress Chaperones 2015; 20:3-13. [PMID: 25181966 PMCID: PMC4255256 DOI: 10.1007/s12192-014-0543-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 02/07/2023] Open
Abstract
Intensive muscular activity can trigger oxidative stress, and free radicals may hence be generated by working skeletal muscle. The role of the enzyme xanthine oxidase as a generating source of free radicals is well documented and therefore is involved in the skeletal muscle damage as well as in the potential transient cardiovascular damage induced by high-intensity physical exercise. Allopurinol is a purine hypoxanthine-based structural analog and a well-known inhibitor of xanthine oxidase. The administration of the xanthine oxidase inhibitor allopurinol may hence be regarded as promising, safe, and an economic strategy to decrease transient skeletal muscle damage (as well as heart damage, when occurring) in top-level athletes when administered before a competition or a particularly high-intensity training session. Although continuous administration of allopurinol in high-level athletes is not recommended due to its possible role in hampering training-induced adaptations, the drug might be useful in non-athletes. Exertional rhabdomyolysis is the most common form of rhabdomyolysis and affects individuals participating in a type of intense exercise to which they are not accustomed. This condition can cause exercise-related myoglobinuria, thus increasing the risk of acute renal failure and is also associated with sickle cell trait. In this manuscript, we have reviewed the recent evidence about the effects of allopurinol on exercise-induced muscle damage. More research is needed to determine whether allopurinol may be useful for preventing not only exertional rhabdomyolysis and acute renal damage but also skeletal muscle wasting in critical illness as well as in immobilized, bedridden, sarcopenic or cachectic patients.
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Affiliation(s)
- F Sanchis-Gomar
- Department of Physiology, University of Valencia, Av. Blasco Ibañez, 15, Valencia, 46010, Spain,
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Nnadi E, Manafa P, Okocha E, Chukwuma G, Aneke J. Evaluation of creatine kinase activity and inorganic phosphate concentration in adult nigerian homozygous and heterozygous hemoglobin phenotypes. Ann Med Health Sci Res 2014; 4:697-700. [PMID: 25328777 PMCID: PMC4199158 DOI: 10.4103/2141-9248.141518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background: Biochemical parameters vary in subjects with different hemoglobin phenotypes, compared with normal controls. Aim: The aim was to evaluate serum creatine kinase (CK) activity and inorganic phosphate concentrations in Nigerian adults with homozygous and heterozygous hemoglobin phenotypes. Subjects and Methods: A prospective study, carried out at the hematology out-patient clinic of our hospital, a community health center and a private hospital, all in Anambra state. Subjects included hemoglobin phenotypes AA, AS, and SS, in steady state and vaso-occlusive crisis (VOC). Samples were collected for serum CK activity and inorganic phosphate concentrations. Data obtained were analyzed using SPSS 16.0 (SPSS Inc., Chicago IL, USA). Means were compared using the Student's t-test and statistical significance was set at P < 0.05. Results: A total of 100 subjects participated in the study. There was a statistically significant difference in the means of serum CK activity in hemoglobin SS (HbSS) in VOC versus hemoglobin AA (HbAA) (P = 0.01) and HbSS in steady state versus HbAA (P = 0.02) but not in hemoglobin AS (HbAS) versus HbAA (P = 0.79) and HbSS in VOC versus HbSS in steady state (P = 0.06). A statistically significant difference was noted in the means of serum inorganic phosphate concentration in HbSS in VOC versus HbAA (P = 0.01), but not in HbSS in steady state versus HbAA (P = 0.43), HbSS in VOC versus HbSS in steady state (P = 0.09) and HbAS versus HbAA (P = 0.20). Conclusion: Sickle cell disease is a predictor for high serum CK activity and low serum concentration of inorganic phosphate, particularly in VOC. There may be a need to monitor serum CK activity in HbSS subjects presenting with major VOC.
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Affiliation(s)
- Ee Nnadi
- Department of Medical Laboratory Science, Nnamdi Azikiwe University, Nnewi, Anambra State, Nigeria
| | - Po Manafa
- Department of Medical Laboratory Science, Nnamdi Azikiwe University, Nnewi, Anambra State, Nigeria
| | - Ec Okocha
- Department of Hematology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Go Chukwuma
- Department of Medical Laboratory Science, Nnamdi Azikiwe University, Nnewi, Anambra State, Nigeria
| | - Jc Aneke
- Department of Hematology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
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Paula Santos U, Zanetta DMT, Terra-Filho M, Burdmann EA. Burnt sugarcane harvesting is associated with acute renal dysfunction. Kidney Int 2014; 87:792-9. [PMID: 25229334 DOI: 10.1038/ki.2014.306] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/10/2014] [Accepted: 07/24/2014] [Indexed: 12/18/2022]
Abstract
Sugarcane harvesting has been associated with an epidemic of chronic kidney disease in Central America mainly affecting previously healthy young workers. Repeated episodes of acute kidney dysfunction are hypothesized to be one of the possible mechanisms for this phenomenon. Therefore, this exploratory study aimed to assess the acute effects of burnt sugarcane harvesting on renal function among 28 healthy non-African Brazilian workers. Urine and blood samples were collected at the beginning and at the end of the harvesting season and before and at the end of a harvesting workday. All individuals decreased their estimated glomerular filtration rate by ∼20% at the end of the daily shift, and 18.5% presented with serum creatinine increases consistent with acute kidney injury. Those changes were associated with increased serum creatine phosphokinase (a known marker for exertional rhabdomyolysis) and oxidative stress-associated malondialdehyde levels, increased peripheral blood white cell counts, decreased urinary and serum sodium, decreased calculated fractional sodium excretion, and increased urine density. Thus, burnt sugarcane harvesting caused acute renal dysfunction in previously healthy workers. This was associated with a combination of dehydration, systemic inflammation, oxidative stress, and rhabdomyolysis.
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Affiliation(s)
- Ubiratan Paula Santos
- Pulmonary Division, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Dirce Maria T Zanetta
- Department of Epidemiology, University of São Paulo Public Health School, São Paulo, Brazil
| | - Mário Terra-Filho
- Pulmonary Division, Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Emmanuel A Burdmann
- Medical Investigation Laboratory 12 (LIM-12), Division of Nephrology, University of São Paulo Medical School, São Paulo, Brazil
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Li Y, Wang Y, Ma L. An association study of CASQ1 gene polymorphisms and heat stroke. GENOMICS, PROTEOMICS & BIOINFORMATICS 2014; 12:127-32. [PMID: 24887214 PMCID: PMC4411341 DOI: 10.1016/j.gpb.2014.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/31/2014] [Indexed: 11/17/2022]
Abstract
Although molecular mechanisms of heat stroke under physiological and pathological conditions have not yet been elucidated, a novel disease-associated gene encoding a calcium-binding protein, calsequestrin-1 (CASQ1), was suggested relevant based on results from a transgenic murine model. Here, we show the association between single nucleotide polymorphisms (SNPs) of CASQ1 and physiological parameters for heat stroke from a study involving 150 patients. Pooled DNA from heat stroke patients were subjected to sequencing and 3 SNPs were identified. Genotypes were assigned for all patients according to g. 175A>G, one SNP which leads to a nonsynonymous substitution (N59D) in the first exon of human CASQ1 gene. We analyzed the genotypic data with a linear model based on significance scores between SNP (175A>G) and heat stroke parameters. As a result, we found a significant association between SNP A175G and heat stroke (P<0.05). Further bioinformatics analysis of the 1-Mb flanking sequence revealed the presence of two genes that encode DDB1 and CUL4 associated factor 8 (DCAF8), and peroxisomal biogenesis factor 19 (PEX19), respectively, which might be functionally related to CASQ1. Our results showed that the blood calcium of patients with allele D increased significantly, compared to patients with allele N (P<0.05), which may result from the decreased calcium in muscle, suggesting that N59D in CASQ1 might account for the dysfunction of CASQ1 in calcium regulation during heat stroke.
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Affiliation(s)
- Ying Li
- Department of Radiology, Chinese PLA Medical School, Beijing 100853, China
| | - Yu Wang
- Department of Health Medicine, Beijing Electric Power Hospital, Beijing 100073, China
| | - Lin Ma
- Department of Radiology, Chinese PLA Medical School, Beijing 100853, China.
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Ishikawa I. [Acute kidney injury: progress in diagnosis and treatments. Topics: IV. Pathophysiology and treatments; 5. Exercise induced AKI]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:1101-1107. [PMID: 25026780 DOI: 10.2169/naika.103.1101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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50
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Medical Services at Ultra-Endurance Foot Races in Remote Environments: Medical Issues and Consensus Guidelines. Sports Med 2014; 44:1055-69. [DOI: 10.1007/s40279-014-0189-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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