Phenotypic variability and molecular genetics in proximal myotonic myopathy.

INTRODUCTION: Myotonic dystrophy type 2 (DM2) is an autosomal dominant inherited disorder with (CCTG)n repeat expansion in intron 1 of the CNBP gene. METHODS: We studied the first 16 Greek DM2 patients who had undergone thorough evaluation. RESULTS: The age at diagnosis ranged from 38 to 69 years. The initial symptoms were proximal weakness, myalgias, and myotonia. Clinical myotonia was elicited in 10 patients, whereas electromyographic myotonic discharges were observed in almost all patients. Subcapsular cataract was frequently present, but cardiac arrhythmias were rare. CONCLUSIONS: In this study of Greek DM2 patients, proximal weakness was the most common initial symptom. Myalgias were also reported in a few patients, yet myotonia was not a major complaint. Although DM2 is considered relatively benign, there are patients who may be affected severely. Thus, a high index of suspicion must be maintained to make a timely diagnosis, especially in those of reproductive age.

Effects of Strength vs. Ballistic-Power Training on Throwing Performance.

The purpose of the present study was to investigate the effects of 6 weeks strength vs. ballistic-power (Power) training on shot put throwing performance in novice throwers. Seventeen novice male shot-put throwers were divided into Strength (N = 9) and Power (n = 8) groups. The following measurements were performed before and after the training period: shot put throws, jumping performance (CMJ), Wingate anaerobic performance, 1RM strength, ballistic throws and evaluation of architectural and morphological characteristics of vastus lateralis. Throwing performance increased significantly but similarly after Strength and Power training (7.0-13.5% vs. 6.0-11.5%, respectively). Muscular strength in leg press increased more after Strength than after Power training (43% vs. 21%, respectively), while Power training induced an 8.5% increase in CMJ performance and 9.0 - 25.8% in ballistic throws. Peak power during the Wingate test increased similarly after Strength and Power training. Muscle thickness increased only after Strength training (10%, p < 0.05). Muscle fibre Cross Sectional Area (fCSA) increased in all fibre types after Strength training by 19-26% (p < 0.05), while only type IIx fibres hypertrophied significantly after Power training. Type IIx fibres (%) decreased after Strength but not after Power training. These results suggest that shot put throwing performance can be increased similarly after six weeks of either strength or ballistic power training in novice throwers, but with dissimilar muscular adaptations. Key pointsBallistic-power training with 30% of 1RM is equally effective in increasing shot put performance as strength training, in novice throwers, during a short training cycle of six weeks.In novice shot putters with relatively low initial muscle strength/mass, short-term strength training might be more important since it can increase both muscle strength and shot put performance.The ballistic type of power training resulted in a significant increase of the mass of type IIx muscle fibres and no change in their proportion. Thus, this type of training might be used effectively during the last weeks before competition, when the strength training load is usually reduced, in order to increase muscle power and shot put performance in novice shot putters.

Deficiency of Dol-P-Man synthase subunit DPM3 bridges the congenital disorders of glycosylation with the dystroglycanopathies.

Alpha-dystroglycanopathies such as Walker Warburg syndrome represent an important subgroup of the muscular dystrophies that have been related to defective O-mannosylation of alpha-dystroglycan. In many patients, the underlying genetic etiology remains unsolved. Isolated muscular dystrophy has not been described in the congenital disorders of glycosylation (CDG) caused by N-linked protein glycosylation defects. Here, we present a genetic N-glycosylation disorder with muscular dystrophy in the group of CDG type I. Extensive biochemical investigations revealed a strongly reduced dolichol-phosphate-mannose (Dol-P-Man) synthase activity. Sequencing of the three DPM subunits and complementation of DPM3-deficient CHO2.38 cells showed a pathogenic p.L85S missense mutation in the strongly conserved coiled-coil domain of DPM3 that tethers catalytic DPM1 to the ER membrane. Cotransfection experiments in CHO cells showed a reduced binding capacity of DPM3(L85S) for DPM1. Investigation of the four Dol-P-Man-dependent glycosylation pathways in the ER revealed strongly reduced O-mannosylation of alpha-dystroglycan in a muscle biopsy, thereby explaining the clinical phenotype of muscular dystrophy. This mild Dol-P-Man biosynthesis defect due to DPM3 mutations is a cause for alpha-dystroglycanopathy, thereby bridging the congenital disorders of glycosylation with the dystroglycanopathies.

Effects of exercise training during infusion on late-onset Pompe disease patients receiving enzyme replacement therapy.

Pompe disease is an autosomal recessive disorder caused by the deficiency of acid α-glucosidase resulting in lysosomal accumulation of glycogen and abnormal autophagic function. The late-onset form of the disease is characterized by progressive skeletal and respiratory muscle dysfunction. Enzyme replacement therapy (ERT, Genzyme Corporation, Cambridge, MA, USA) was recently introduced and resulted in significant prolongation of the life expectancy of the patients with the infantile form while the results were less significant for the late-onset form. It has been postulated that the weak influence of ERT in late-onset patients might be due to a non-effective delivery of the recombinant enzyme to the skeletal muscles perhaps due to the relatively low blood flow to the resting skeletal muscles during infusion. Exercise training acutely increases the blood flow to the exercising muscles. Thus, it was hypothesized that exercise training during enzyme infusion might increase the effectiveness of the ERT therapy. Five late-onset Pompe disease patients receiving ERT and following regular exercise training for approximately 10 months, followed a 6-month period of exercise training during infusion of the recombinant enzyme. Before and after this period, body composition, isometric strength and 6 minute walking distance were determined. Analysis of the results revealed that none of these parameters changed significantly after the 6-month intervention period (e.g. 6 minute walking distance before: 532±31 m, vs. after: 527±29 m, P=0.246). These results suggest that exercise training during infusion may not add significant functional changes in late-onset Pompe patients receiving ERT and undergoing regular exercise training.

Effect of aerobic and resistance exercise training on late-onset Pompe disease patients receiving enzyme replacement therapy.

Pompe disease is a rare autosomal recessive disorder characterized by the deficiency of acid α-glycosidase resulting in lysosomal accumulation of glycogen. The late-onset disease form is characterized by progressive skeletal and respiratory muscle dysfunction. In addition to the recently introduced enzyme replacement therapy (ERT), treatments such as protein-enriched diet and exercise training have been proposed, although little is known about their effectiveness on the physical condition of such patients. Aim of the present study was to investigate the effect of exercise training on muscular strength and body composition in five patients with late-onset Pompe disease receiving ERT. All subjects followed a 20 week lasting program of supervised aerobic and progressive resistance exercise training. Before and after the training period, body composition was determined with dual X-ray absorptiometry and isometric muscular strength was measured with a specialized load transducer. Functional capacity was assessed using the 6-min shuttle walk test. A significant increase in muscular strength (15-50% at various body parts, p<0.05) and 6-minute walking distance (203.8 ± 177 m before vs. 248.2 ± 184 m after, p<0.01) was observed after training, whereas total and lower extremities lean body mass did not change significantly. These results suggest that exercise training has a positive effect on muscular strength and functional capacity in patients on ERT with late-onset Pompe disease.

The degree of p70 S6k and S6 phosphorylation in human skeletal muscle in response to resistance exercise depends on the training volume.

Regular performance of resistance exercise induces an increase in skeletal muscle mass, however, the molecular mechanisms underlying this effect are not yet fully understood. The purpose of the present investigation was to examine acute changes in molecular signalling in response to resistance exercise involving different training volumes. Eight untrained male subjects carried out one, three and five sets of 6 repetition maximum (RM) in leg press exercise in a random order. Muscle biopsies were taken from the vastus lateralis both prior to and 30 min after each training session and the effect on protein signalling was studied. Phosphorylation of Akt was not altered significantly after any of the training protocols, whereas that of the mammalian target of rapamycin was enhanced to a similar extent by training at all three volumes. The phosphorylation of p70S6 kinase (p70(S6k)) was elevated threefold after 3 × 6 RM and sixfold after 5 × 6 RM, while the phosphorylation of S6 was increased 30- and 55-fold following the 3 × 6 RM and 5 × 6 RM exercises, respectively. Moreover, the level of the phosphorylated form of the gamma isoform of p38 MAPK was enhanced three to fourfold following each of the three protocols, whereas phosphorylation of ERK1/2 was unchanged 30 min following exercise. These findings indicate that when exercise is performed in a fasted state, the increase in phosphorylation of signalling molecules such as p70(S6k) and the S6 ribosomal protein in human muscle depends on the exercise volume.

Muscle fibre type composition and body composition in hammer throwers.

Aim of the present study was to describe the muscle fibre type composition and body composition of well-trained hammer throwers. Six experienced hammer throwers underwent the following measurements: one repetition maximum in squat, snatch, and clean, standing broad jump, backward overhead shot throw and the hammer throw. Dual x-ray absorptiometry was used for body composition analysis. Fibre type composition and cross sectional area was determined in muscle biopsy samples of the right vastus lateralis. Eight physical education students served as a control group. One repetition maximum in squat, snatch and clean for the hammer throwers was 245 ± 21, 132 ± 13 and 165 ± 12kg, respectively. Lean body mass was higher in hammer throwers (85.9 ± 3. 9kg vs. 62.7 ± 5.1kg (p < 0.01). The percentage area of type II muscle fibres was 66.1 ± 4% in hammer throwers and 51 ± 8% in the control group (p < 0.05). Hammer throwers had significantly larger type IIA fibres (7703 ± 1171 vs. 5676 ± 1270µm(2), p < 0.01). Hammer throwing performance correlated significantly with lean body mass (r = 0.81, p < 0.05). These data indicate that hammer throwers have larger lean body mass and larger muscular areas occupied by type II fibres, compared with relatively untrained subjects. Moreover, it seems that the enlarged muscle mass of the hammer throwers contributes significantly to the hammer throwing performance. Key pointsWell-trained hammer throwers had increased lean body mass, higher type IIA muscle fibres cross sectional areas, as well as higher bone mineral density, compared to controls.Increased lean body mass was closely related with hammer throwing performance.The relative high percentage of type IIX muscle fibres in vastus lateralis in hammer throwers warrants further investigation.

Asymptomatic elevation of serum creatine kinase leading to the diagnosis of 4q35 facioscapulohumeral muscular dystrophy.

Persistent, asymptomatic (hyperCKemia) may be the prelude to, or the sole manifestation of, a neuromuscular disease. However, the clinical spectrum of facioscapulohumeral muscular dystrophy (FSHD) ranges from asymptomatic individuals with minimal clinical signs to patients who are wheelchair-bound. We describe a patient with persistent, asymptomatic hyperCKemia who received the diagnosis of 4q35 FSHD after a thorough stepwise investigation.

Age-related morphometric characteristics of human skeletal muscle in male subjects.

OBJECTIVE: The purpose of the present study is to investigate the age-related changes in muscle biopsies from the quadriceps femoris in male subjects of different ages. METHODS: A histological and histochemical study was performed on specimens from the quadriceps femoris from 8 males divided into two groups, under 50 and over 70 years of age. The following measurements were performed: a) number of type 1 and 2 fibres, b) diameter of type 1 and 2 fibres, c) percentage of the number and mean diameter of the two types in the interior and the peripheral area of fascicles. RESULTS: The proportion of type 2 fibres decreased significantly with age (p < 0.005), especially in the periphery of the fascicles, but the proportion of type 1 fibres was not significantly changed. The correlation of fibre size with age showed that type 2 fibres decrease in size with age. This finding was more evident in the periphery of the fascicles (p < 0.05). CONCLUSION: We found that type 2 skeletal muscle fibres decreased in size and proportion with increasing age. The existence of these age changes should be taken into account in the interpretation of muscle biopsies of aged individuals.

Acute effect of drop jumping on throwing performance.

The purpose of the present study was to investigate the acute effect of drop jumping on throwing performance. Eight men and 8 women, moderately trained subjects with basic shot put skills, performed 3 squat underhand front shot throws after a short standard warm-up. Three minutes later they performed 5 maximal consecutive drop jumps from 40 cm. Immediately after the drop jumps, they repeated the squat underhand front shot throws. On another day, their 6 repetition maximum (RM) muscular strength in leg press was assessed. Muscle biopsies were also obtained from vastus lateralis for the determination of fiber-type composition and fiber cross-sectional area. Throwing performance was significantly increased after drop jumping (8.25 +/- 1.1 m vs. 8.63 +/- 1.3 m, p < 0.01). The percentage of type II muscle fiber area was significantly related to the increase in throwing performance after drop jumping (r = 0.76, p < 0.01). The increase in throwing performance was significant in men (8.94 +/- 1 m vs. 9.60 +/- 0.9 m, p < 0.01) but not in women (7.56 +/- 1 m vs. 7.67 +/- 0.9 m, ns). Of note, the percentage of type II fiber area was higher in men than in women (M: 66.4 +/- 13%, F: 50.2 +/- 15%, p < 0.01). Leg press strength (6RM) was moderately related to the increase in throwing performance after drop jumping (r = 0.50, p < 0.05). These results suggest that drop jumping just before a throwing action induces an increase in performance in subjects with a high percentage of type II muscle fiber area and (to a lesser degree) in subjects with enhanced muscular strength.

Sarcoidosis in a case of MuSK-positive myasthenia gravis.

Whereas the coexistence of different autoimmune or rheumatologic diseases with myasthenia gravis is well documented, the combination of myasthenia with sarcoidosis is extremely rare. There very few case reports of patients suffering from these two immune-mediated diseases. Nearly all had acetylcholine receptor antibodies. As far as we know myasthenia gravis with antibodies to muscle-specific tyrosine kinase-MuSK--has not been associated with any form of sarcoidosis. We present probably the first case of MuSK-positive myasthenia gravis with concurrent, asymptomatic pulmonary sarcoidosis.

Dropped head syndrome as prominent clinical feature in MuSK-positive Myasthenia Gravis with thymus hyperplasia.

MuSK-positive Myasthenia Gravis is in most cases clinically characterized by a progressive course with severe oculobulbar involvement or prominent neck, shoulder and respiratory muscle weakness. It is also distinguished from other forms of myastehnia through its lack of germinal centers or lymphocytic infiltrates in the thymic tissue. We present the case of a MuSK-positive female myasthenic patient with over four years slowly progressive weakness of the neck extensor muscles in the presence of thymus hyperplasia and discuss its uncommon and markedly focal clinical and electrophysiological features, as well as the excellent course under medication with pyridostigmine and prednisone, especially after thymectomy.

Resistance exercise-induced increase in muscle mass correlates with p70S6 kinase phosphorylation in human subjects.

The purpose of the present study was to investigate the possible relationship between a change in Thr(389) phosphorylation of p70S6 kinase (p70(S6k)) after a single resistance training session and an increase in skeletal muscle mass following short-term resistance training. Eight male subjects performed an initial resistance training session in leg press, six sets of 6RM with 2 min between sets. Muscle biopsies were obtained from the vastus lateralis before (T1) and 30 min after the initial training session (T2). Six of these subjects completed a 14-week resistance-training programme, three times per week (nine exercises, six sets, 6RM). A third muscle biopsy was obtained at the end of the 14-week training period (T3). One repetition maximum (1RM) squat, bench press and leg press strength as well as fat-free mass (FFM, with dual energy X-ray absorptiometry) were determined at T1 and T3. The results show that the increase in Thr(389) phosphorylation of p70(S6k) after the initial training session was closely correlated with the percentage increase in whole body FFM (r = 0.89, P < 0.01), FFM(leg) (r = 0.81, P < 0.05), 1RM squat (r = 0.84, P < 0.05), and type IIA muscle fibre cross sectional area (r = 0.82, P < 0.05) after 14 weeks of resistance training. These results may suggest that p70(S6k) phosphorylation is involved in the signalling events leading to an increase in protein accretion in human skeletal muscle following resistance training, at least during the initial training period.

Throwing performance after resistance training and detraining.

The purpose of the present study was to investigate the effect of short-term resistance training and detraining on shot put throwing performance. Eleven young healthy subjects with basic shot put skills participated in 14 weeks of resistance training, which was followed by 4 weeks of detraining. Shot put performance in four field tests was measured before (T1) and after (T2) resistance training and after detraining (T3). At the same time points, one repetition maximum (1RM) was measured in squat, bench press, and leg press. Fat-free mass (FFM) was determined with dual x-ray absorptiometry and muscle biopsies obtained from vastus lateralis for the determination of fiber type composition and cross-sectional area (CSA). 1RM strength increased 22-34% (p < 0.01) at T2 and decreased 4-5% (not significantly different) at T3. Shot put performance increased 6-12% (p < 0.05) after training and remained unaltered after detraining. FFM increased at T2 (p < 0.05) but remained unchanged between T2 and T3. Muscle fiber CSA increased 12-18% (p < 0.05) at T2. Type I muscle fiber CSA was not altered after detraining, but type IIa and IIx fiber CSA was reduced 10-12% (p < 0.05). The percentage of type IIx muscle fibers was reduced after training (T1 = 18.7 +/- 4, T2 = 10.4 +/- 1; p < 0.05), and it was increased at T3 compared with T2 (T3 = 13.7 +/- 1; p < 0.05). These results suggest that shot put performance remains unaltered after 4 weeks of complete detraining in moderately resistance-trained subjects. This might be linked to the concomitant reduction of muscle fiber CSA and increase in the percentage of type IIx muscle fibers.

Fiber type composition and capillary density in relation to submaximal number of repetitions in resistance exercise.

The purpose of this study was to investigate the relationship between skeletal muscle fiber type composition and the maximum number of repetitions performed during submaximal resistance exercise. Twelve young men performed a maximum repetitions test at 85% of 1 repetition maximum (1RM) in the leg press, which was repeated after 1 week. Seven days after the second 85% 1RM test, they performed a maximum repetitions test at 70% of 1RM in the leg press. This test, at 70% 1RM, was repeated 7 days later. One week before the initiation of the testing sessions, a biopsy sample was obtained from the vastus lateralis muscle and analyzed for fiber type distribution, fiber cross-sectional area, and capillary density (capillaries x mm(2)). A low and nonsignificant relationship was found between the fiber type distribution or percent fiber type area and the number of repetitions performed at either 70% or 85% 1RM. Moreover, the number of repetitions performed at 70% or 85% of 1RM was not related significantly with 1RM strength. In contrast, the number of repetitions performed at 70% 1RM was significantly correlated with the number of capillaries per mm(2) of muscle cross-sectional area (r = 0.70; p = 0.01). These results suggest that fiber type composition is not the major biological variable regulating the number of repetitions performed in submaximal resistance exercise. Rather, it seems that submaximal strength performance depends on muscle capillary density, which is linked with the endurance capacity of the muscle tissue.

Presymptomatic neuromuscular disorders disclosed following statin treatment.

It is well recognized that statins affect muscular tissue adversely and that their use is associated with clinically important myositis, rhabdomyolysis, mild elevation of serum creatine kinase (CK) levels, myalgias, muscle weakness, muscle cramps, and persistent myalgias or serum CK level elevations after statin treatment is discontinued. The association between statins and the disclosure of presymptomatic metabolic myopathy is another underrated phenomenon related to statin therapy that was recently recognized in rare cases. The purpose of this report is to provide additional support for this association and to report other neuromuscular disorders that have also been seen following statin intake. The present case series illustrates that statins may act as unmasking agents in asymptomatic patients with a latent neuromuscular disorder. Thus, it may be postulated that statin intake may be a sufficient insult to precipitate neuromuscular symptoms and substantially increase muscle enzymes in presymptomatic patients with an abnormal neuromuscular substrate. In conclusion, muscular symptoms or increased serum CK levels persisting after statin treatment discontinuation should alert the clinician to pursue further diagnostic evaluations for the detection of potential underlying neuromuscular diseases.

Validation of the ABCD score in identifying individuals at high early risk of stroke after a transient ischemic attack: a hospital-based case series study.

BACKGROUND AND PURPOSE: A simple score derived in the Oxfordshire Community Stroke Project (ABCD score) was able to identify individuals at high early risk of stroke after a transient ischemic attack (TIA) both in a population-based and a hospital-referred clinic cohort. We aimed to further validate the former score in a cohort of hospitalized TIA patients. METHODS: We retrospectively reviewed the emergency room and hospital records of consecutive patients hospitalized in our neurological department with a definite TIA according to the World Health Organization (WHO) criteria during a 5-year period. The 6-point ABCD score (age [<60 years=0, > or =60 years=1]; blood pressure [systolic < or =140 mm Hg and diastolic < or =90 mm Hg=0, systolic >140 mm Hg and/or diastolic >90 mm Hg=1]; clinical features [unilateral weakness=2, speech disturbance without weakness=1, other symptom=0]; duration of symptoms [<10 minutes=0, 10 to 59 minutes=1, > or =60 minutes=2]) was used to stratify the 30-day stroke risk. RESULTS: The 30-day risk of stroke in the present case series (n=226) was 9.7% (95% CI, 5.8% to 13.6%). The ABCD score was highly predictive of 30-day risk of stroke (ABCD=0 to 2: 0%, ABCD=3: 3.5% [95% CI, 0% to 8.2%], ABCD=4: 7.6% [95% CI, 1.2% to 14.0%], ABCD=5: 21.3% [95% CI, 10.4% to 33.0%], ABCD=6: 31.3% [95% CI, 8.6% to 54.0%]; log-rank test=23.09; df=6; P=0.0008; P for linear trend across the ABCD score levels <0.00001). After adjustment for stroke risk factors, history of previous TIA, medication use before the index TIA, and secondary prevention treatment strategies, an ABCD score of 5 to 6 was independently (P<0.001) associated with an 8-fold greater 30-day risk of stroke (hazard ratio, 8.01; 95% CI, 3.21 to 19.98). CONCLUSIONS: Our findings validate the predictive value of the ABCD score in identifying hospitalized TIA patients with a high risk of early stroke and provide further evidence for its potential applicability in clinical practice.