Effect of creatine monohydrate in improving cellular energetics and muscle strength in ambulatory Duchenne muscular dystrophy patients: a randomized,placebo-controlled P MRS study

Randomized, placebo-controlled single blinded study was carried out to evaluate the effect of oral creatine supplementation on cellular energetics, manual muscle test (MMT) score and functional status in steroid-naive, ambulatory boys suffering with Duchenne muscular dystrophy (DMD; n=33). Eighteen patients received creatine monohydrate (Cr; 5 g/day for 8 weeks), while 15 received placebo (500 mg of vitamin C). Phosphorus metabolite ratios were determined from the right calf muscle of patients using phosphorus magnetic resonance spectroscopy (³¹P MRS) both prior to (baseline) and after supplementation of Cr or placebo. In addition, metabolite ratios were determined in normal calf muscle of age and sex matched controls (n=8). Significant differences in several metabolite ratios were observed between controls and DMD patients indicating a lower energy state in these patients. Analysis using analysis of covariance adjusted for age and stature showed that the mean phosphocreatine (PCr)/inorganic phosphate (Pi) ratio in patients treated with Cr (4.7; 95% CI; 3.9–5.6) was significantly higher (P=.03) compared to the placebo group (3.3; 95% CI; 2.5–4.2). The mean percentage increase in PCr/Pi ratio was also more in patients <7 years of age compared to older patients after Cr supplementation indicating variation in therapeutic effect with the age. In the placebo group, significant reduction in PCr/Pi (P=.0009), PCr/t-ATP (P=.05) and an increase in phosphodiester (PDE)/PCr ratios was observed after supplementation. Further, in the placebo group, patients <7 years showed reduction of PCr/t-ATP and Pi/t-ATP compared to older patients (>7 years), after supplementation. These results imply that the significant difference observed in PCr/Pi ratio between the Cr and the placebo groups after supplementation may be attributed to a decrease of PCr in the placebo group and an increase in PCr in the Cr group. Changes in MMT score between the two groups was significant (P=.04); however, no change in functional scale (P=.19) was observed. Parents reported subjective improvement on Cr supplementation versus worsening in placebo (P=.02). Our results indicated that Cr was well tolerated and oral Cr significantly improved the muscle PCr/Pi ratio and preserved the muscle strength in short term. However, this study provides no evidence that creatine will prove beneficial after long-term treatment, or have any positive effect on patient lifespan.     

鼠S180肉瘤的体内31P MRS研究

利用表面线圈³¹P NMR研究了小鼠S180肉瘤生长过程中能量代谢和磷脂类变化的特点.结果发现:随着肿瘤体积的增大,(1)Pi和PME升高;(2)PCr降低,在肿瘤体积较大时常检测不到;(3)β-NTP(通常用来表示ATP的量)变化较小;(4)PDE波动性较大;(5)PCr/Pi和β-NTP/Pi比值均下降,且PCr/Pi比β-NTP/Pi下降得快;(6)PME/β-NTP比值升高;(7)肿瘤pH下降,且与PCr/Pi、β-NTP/Pi或(PCr+β-NTP)/Pi比值有相关性.讨论了与这些参数变化相关联的生物学意义.     

Bio-energetic impairment in human calf muscle in thyroid disorders: a P MRS study

Mitochondrial metabolism particularly oxidative phosphorylation is greatly influenced by thyroid hormones. Earlier studies have described neuromuscular symptoms as well as impaired muscle metabolism in hypothyroid and hyperthyroid patients. In this study, we intend to look in to the muscle bioenergetics including phosphocreatine recovery kinetics based oxidative metabolism in thyroid dysfunction using in vivo ³¹P nuclear magnetic resonance spectroscopy (MRS). ³¹P MRS was carried out at resting state on 32 hypothyroid, 10 hyperthyroid patients and 25 control subjects. Nine out of 32 hypothyroid patients and 17 out of 25 control subjects under went exercise protocol for oxidative metabolism study and performed plantar flexion exercise while lying supine in 1.5 T magnetic resonance scanner using custom built exercise device. MRS measurements of inorganic phosphate (Pi), phosphocreatine (PCr), phosphodiesters (PDE) and adenosine triphosphate (ATP) of the calf muscle were acquired during rest, exercise and recovery phase. PCr recovery rate constant (k_PCr) and oxidative capacity were calculated by monoexponential fit of PCr versus time (t) at the beginning of recovery. During resting condition in hypothyroid patients, PCr/Pi ratio was reduced whereas PDE/ATP and Pi/ATP were increased. However, in case of hyperthyroidism, an increased PCr/Pi ratio and reduced PDE/ATP and Pi/ATP were observed. The results confirmed differential energy status of the muscle due to increased or decreased levels of thyroid hormone. Our results also demonstrate reduced oxidative metabolism in hypothyroid patients based on PCr recovery kinetics. PCr recovery kinetics study after exercise revealed decreased PCr recovery rate constant (k_PCr) in hypothyroid patients compared to controls that resulted in decrease in oxidative capacity of muscle by 50% in hypothyroids. These findings are consistent with a defect of high energy phosphate mitochondrial metabolism in thyroid dysfunction.     

Simultaneous acquisition of phosphocreatine and inorganic phosphate images for Pi:PCr ratio mapping using a RARE sequence with chemically selective interleaving

The ratio of inorganic phosphate to phosphocreatine (Pi:PCr) is a validated marker of mitochondrial function in human muscle. The magnetic resonance imaging rapid acquisition with relaxation enhancement (RARE) pulse sequence can acquire phosphorus-31 (³¹P) images with higher spatial and temporal resolution than traditional spectroscopic methods, which can then be used to create Pi:PCr ratio maps of muscle regions. While the ³¹P RARE method produces images that reflect the content of the ³¹P metabolites, it has been limited to producing an image of only one chemical shift in a scan. This increases the scan time required to acquire images of multiple chemical shifts as well as the likelihood of generating inaccurate Pi:PCr maps due to gross motion. This work is a preliminary study to demonstrate the feasibility of acquiring Pi and PCr images in a single scan by interleaving Pi and PCr chemical shift acquisitions using a chemically selective radiofrequency excitation pulse. The chemical selectivity of the excitation pulse evaluated and the Pi:PCr maps generated using the interleaved Pi and PCr acquisition method with the subject at rest and during exercise are compared to those generated using separate Pi and PCr acquisition scans. A paired t test indicated that the resulting Pi:PCr ratios for the exercised forearm muscle regions were not significantly different between the separate Pi and PCr acquisition method (3.18±1.53) (mean±standard deviation) and the interleaved acquisition method (3.41±1.66). This work demonstrates the feasibility of creating Pi:PCr ratio maps in human muscle with Pi and PCr images acquired simultaneously by interleaving between the Pi and PCr resonances in a single scan.     

In vivo proton magnetic resonance spectroscopy (MRS) study of post polio residual paralysis (PPRP) patients

In-vivo proton MR spectroscopy carried out on post polio residual paralysis (PPRP) patients indicate that the presence or absence of intra-myocellular lipids (IMCL) is related to the severity of the paralysis. It is observed that mildly paralyzed patients are comparable (p > 0.05) with the control subjects in relation to the presence of IMCL, while moderate and severely paralysed patients are comparable (p > 0.05) in relation to the absence of IMCL. In addition, there is reduction or complete absence of creatine, carnitine and choline metabolites in severely paralyzed patients. The ability to detect noninvasively the subtle differences in in vivo, the lipid compartments of muscle may prove to be a valuable tool in understanding the pathogenesis of muscle diseases. This could open up the possibilities in designing effective rehabilitative exercise programs or development of new drug therapies.     

Relayed magnetization transfer from nuclear Overhauser effect and chemical exchange observed by in vivo ³¹P MRS in rat brain

The ³¹P magnetization transfer effects among nuclear magnetic resonances (NMRs) of phosphocreatine (PCr), γ-adenosine-5'-triphosphate (γ-ATP) and inorganic phosphate (Pi) have been attributed to the chemical exchange reactions among PCr, ATP and Pi catalyzed by creatine kinase (CK) and ATPase enzymes and, therefore, are commonly applied in situ to measure chemical exchange fluxes involving two chemically coupled CK and ATPase reactions (i.e., PCr↔ATP↔Pi) by selectively saturating γ-ATP resonance. Besides the expected reductions in the Pi and PCr NMR signals upon saturating γ-ATP resonance, one particularly interesting phenomenon showing decreases in α-ATP and β-ATP signals was also observed. The underlying mechanism was investigated and identified via saturating NMR of β-ATP in the present study. The unique relayed magnetization transfer effects through spin diffusion were observed in the rat brain using in vivo ³¹P magnetic resonance spectroscopy.     

小鼠大脑急性缺血过程中31P NMR研究

利用³¹P NMR研究了小鼠大脑在急性缺血状态下能量代谢的特点,结扎带迷走神经的颈总动脉后,PCr/Pi、β-ATP/Pi比值迅速下降,且PCr/Pi下降速度较快,同时脑细胞内酸中毒加重.缺血5min后恢复供血,可部分地逆转缺血造成的损伤.     

用3lP NMR研究小鼠脑在缺氧状态下能量代谢的动态变化

用³¹P体内核磁共振方法无损伤地观察了C57小鼠脑在缺氧时与能量代谢有关的含磷化合物Pi,PCr,ATP的动态变化,当气体中氧气含量降到5%时,小鼠大脑的PCr,ATP逐渐减少,Pi不断增加,脑组织内pH值降低至6.83~6.93.当Pi与PCr的峰高比等于1时给予复氧,发现复氧时Pi立即降低且pH立即升高的小鼠可以恢复,反之则不可恢复,表明Pi和pH反映了大脑缺氧损伤程度.     

大鼠急性缺血心肌31P磁共振波谱的基础研究

利用³¹P磁共振波谱（MRS）检测了急性缺血心肌组织提取物中高能磷酸化合物的变化. 方法：成年SD大鼠在心肌梗塞后0、5、 20、45 min后进行取材,梗塞区、边缘区及正常区的心肌组织经高氯酸萃取后进行高分辨MRS检测. 结果：梗塞区,缺血5 min PCr/Pi比值下降到对照组的12 ％;20 min ATP/Pi 比值下降至0.05,Pi/EPP比值上升至0.8;45 min 梗塞区PDE/ATP上升至1.93,与45 min心肌的不可逆损伤超微结构相吻合. 边缘区各代谢产物出现改变的程度要小于梗塞区,大于正常区. 正常区也有能量代谢的改变. 结论：心肌组织的³¹P MRS能够反映心肌缺血后心肌不同部位的动态能量代谢改变. PDE/ATP是判断心肌不可拟性损伤的可靠指标.     

紫杉醇治疗小鼠S180肉瘤的体内31P MRS研究

为了研究紫杉醇治疗小鼠S180肉瘤的³¹P MRS参数的变化及这些参数的变化是否早于常规观察的瘤体积的变化.方法:利用表面线圈³¹P NMR方法,研究小鼠皮下接种的S180肉瘤.结果:用药48h后给药组的PCr/Pi、β-NTP/Pi、PME/β-NTP比值与对照组有显著性差别(P<0.05),而肿瘤体积在给药组和对照组之间无显著性差别,³¹P MRS参数的变化早于瘤体积变化.结论:小鼠S180肉瘤³¹P MRS不仅可以给出定量的结果,而且可以较早地显示出治疗的效果.     

Phosphorus-31 MR spectroscopic imaging (MRSI) of normal and pathological human brains.

The goals of this study were to evaluate 31P MR spectroscopic imaging (MRSI) for clinical studies and to survey potentially significant spatial variations of 31P metabolite signals in normal and pathological human brains. In normal brains, chemical shifts and metabolite ratios corrected for saturation were similar to previous studies using single-volume localization techniques (n = 10; pH = 7.01 +/- 0.02; PCr/Pi = 2.0 +/- 0.4; PCr/ATP = 1.4 +/- 0.2; ATP/Pi = 1.6 +/- 0.2; PCr/PDE = 0.52 +/- 0.06; PCr/PME = 1.3 +/- 0.2; [Mg2+]free = 0.26 +/- 0.02 mM.) In 17 pathological case studies, ratios of 31P metabolite signals between the pathological regions and normal-appearing (usually homologous contralateral) regions were obtained. First, in subacute and chronic infarctions (n = 9) decreased Pi (65 +/- 12%), PCr (38 +/- 6%), ATP (55 +/- 6%), PDE (47 +/- 9%), and total 31P metabolite signals (50 +/- 8%) were observed. Second, regions of decreased total 31P metabolite signals were observed in normal pressure hydrocephalus (NPH, n = 2), glioblastoma (n = 2), temporal lobe epilepsy (n = 2), and transient ischemic attacks (TIAs, n = 2). Third, alkalosis was detected in the NPH periventricular tissue, glioblastoma, epilepsy ipsilateral ictal foci, and chronic infarction regions; acidosis was detected in subacute infarction regions. Fourth, in TIAs with no MRI-detected infarction, regions consistent with transient neurological deficits were detected with decreased Pi, ATP, and total 31P metabolite signals. These results demonstrate an advantage of 31P MRSI over single-volume 31P MRS techniques in that metabolite information is derived simultaneously from multiple regions of brain, including those outside the primary pathological region of interest. These preliminary findings also suggest that abnormal metabolite distributions may be detected in regions that appear normal on MR images.     

In vivo muscle magnetic resonance spectroscopy in a family with mitochondrial cytopathy: a defect in fat metabolism

In vivo proton and phosphorus magnetic resonance spectroscopy (MRS) studies were performed at 1.5 T on two patients (siblings) diagnosed as having a mitochondrial cytopathy. The clinical diagnosis was based on a complete battery of biochemical tests, electron microscopy and modified Gomori trichrome stain studies of muscle. Proton spectra from the gastrocnemius muscle were recorded using the stimulated echo acquisition mode (STEAM) and the phosphorus spectra were obtained using the depth-resolved surface coil spectroscopy (DRESS) sequence. Proton resonances from neutral fats in the patients were found to be strikingly weak compared to normals. The ratios [PCr]/[ATP] and [PCr]/[Pi] and the pH values, as inferred from the phosphorus MRS, were found to be marginally decreased compared to normals. These studies indicate defective fatty acid metabolism in these two patients. It is, however, not known whether the abnormal mitochondrial ultrastructure represents a primary abnormality or secondary to defective fatty acid metabolism.     

High-energy phosphate metabolism during incremental calf exercise in humans measured by 31 phosphorus magnetic resonance spectroscopy (31P MRS)

Several previous 31 phosphorus magnetic resonance spectroscopy ((31)P MRS) studies performing incremental or progressive muscle exercises have observed that a decrease in pH is accompanied with an acceleration in phosphocreatine (PCr) hydrolysis. The purpose of this study was to investigate the relationship between PCr breakdown and pH during isotonic, exhaustive, incremental plantar flexion exercises. We included eight healthy, male volunteers into this study. Using a 1.5 Tesla MR scanner and a self-built exercise bench, we performed serial free induction decay (FID) (31)P MRS measurements with a time resolution of 1 min at rest, isotonic calf muscle exercise, and recovery. The exercise protocol consisted of 5-min intervals with 4.5, 6, 7.5, and 9 W workload followed by 9-min recovery. Changes in PCr and inorganic phosphate (Pi) were determined as percent changes in comparison to the baseline. In addition, pH values were calculated. This study obtained significant decreases in PCr corresponding to the gradual increases in workload. In each workload level that was succeeded by all volunteers, PCr hydrolysis passed into a steady state. After an early biphasic response, we detected a significant decrease in pH from the first to the second minute of the 6-W workload level followed by a further continuous decrease in pH up to the second minute of the recovery phase. The decrease in pH was not accompanied by acceleration in PCr hydrolysis. In conclusion, this study shows that PCr hydrolysis during incremental plantar flexion exercises passes into a steady state at different workload levels. The observed decrease in pH does not result in acceleration of PCr hydrolysis.     

活体动物代谢过程的31P NMR研究——方法与初步结果

利用表面线圈探头测得了小鼠大脑,大腿肌肉和肝脏的体内³¹P NMR谱图。观察到PCr,ATP,PME,PDE,P_i等化合物的共振峰,并确定了各谱峰的化学位移。由大脑的P_i化学位移计算得到其细胞内pH值为7.15.用差谱方法解决了因定位不准而造成的肝脏谱图不纯。观察了小鼠大脑在缺氧状态下的代谢变化过程。当O₂浓度降至2%时,PCr开始下降,降到1%时,P_i明显升高。从空气变化到1%的O₂含量,致使小鼠死亡,小鼠大脑的pH值从7.16降到6.46。     

Effect of exercise on the creatine resonances in 1H MR spectra of human skeletal muscle

1H MR spectra of human muscles were recorded before, during, and after fatiguing exercise. In contrast to expectations, it was found that the spectral contributions of creatine/phosphocreatine (Cr/PCr) were subject to change as a function of exercise. In particular, the dipolar-coupled methylene protons of Cr/PCr were found to be reduced in intensity in proportion to the co-registered PCr levels. Recovery after exercise and behavior under ischemic conditions provide further evidence to suggest that the contributions of the CH2 protons of Cr/PCr to 1H MR spectra of human muscle in vivo reflect PCr rather than Cr levels. Variation of experimental parameters showed that this effect is not due to a trivial change in relaxation times. At present it can only be speculated about why the Cr resonances have reduced NMR visibility. If temporary binding to macromolecules should be involved, the free Cr concentration-important for equilibrium calculations of the creatine kinase reaction-might be different from what was previously assumed.     

急性低氧大鼠脑31P核磁共振波谱研究

³¹P磁共振波谱是目前唯一可以用作在体无损伤的检测细胞水平能量代谢变化的非侵入性技术,可测得脑内多种能量代谢产物.目的：急性低氧大鼠脑组织的³¹P MRS检测.方法：(1)20只成年SD大鼠分为4组：低氧0min(对照),5min,10min,15min后,迅速液氮冷冻;(2)将脑组织研碎后,加入高氯酸(PCA),冷冻干燥;(3)将提取物用0.5mL D\-2O溶解后进行MRS检测.结果：(1)急性低氧早期即引起³¹P MRS中PCr和ATP峰降低,ADP和Pi峰增高,PCr/Pi和ATP/Pi降低,而ADP/ATP增高.可交换磷池(EPP)中PCr的正常值为42.4%,低氧5min后降到28.9%, ATP从33.8%降到19.2%,Pi从17.7%升到42.0%.(2)急性低氧时³¹P MRS中脑内磷酯分解代谢产物GPC、GPE含量增加,说明低氧早期脑内即有膜磷酯的分解增加.结论：³¹P磁共振波谱可用于脑低氧性疾病的诊断,我们波谱中最敏感的指标是PCr/Pi和ATP/Pi,尤其早期降低更为显著.     

Application of spectroscopic imaging in epilepsy

Functional and anatomical neuroimaging has had a dramatic effect on the evaluation of patients for seizure surgery. The demonstration by PET that the epileptogenic focus has interictal metabolic abnormalities has allowed a greater number of patients to come to seizure surgery, with fewer of these patients requiring intracranial electrode evaluations. Metabolic changes have also been demonstrated utilizing single voxel and whole brain ¹H and ³¹P MRS imaging techniques with the interictal focus characterized by increased Pi, pH, and decreased PME and NAA. These findings can be used to accurately lateralize temporal lobe as well as frontal lobe epilepsy. Furthermore, there is evidence that these findings can be used to localize the seizure focus with the changes specific for the epileptogenic region; although, more diffuse changes both ipsilaterally and contralaterally have been seen. In patients with anterior hippocampal seizure foci the pH is significantly alkaline only in the ipsilateral hippocampus, whereas the increased Pi and decreased PME can be seen throughout the ipsilateral temporal lobe. When compared to controls the contralateral hemisphere is acidotic. Decreased NAA concentrations as well as NAA/Cr ratios have been demonstrated in the epileptogenic region in temporal and frontal lobe epilepsy. The decreased NAA has been correlated with the severity of cell loss, and may be a more sensitive measure than qualitative or quantitative measures of the hippocampal atrophy; however, the NAA decrease is more widespread than just the epileptogenic focus but may be maximal at the site of seizure initiation. In preliminary work, NAA maps of deviation from normality have suggested the maximal change to coincide with the epileptogenic region. These results suggest that in focal epilepsy there is abnormal metabolic activity throughout the brain detectable by MRS, with patterns of metabolic asymmetry that are useful for seizure localization.     

In vivo 31P-MRS assessment of muscle-pH, cytolsolic-[Mg2+] and phosphorylation potential after supplementing hypokaliuric renal stone patients with potassium and magnesium salts

Renal stone patients in rural northeast Thailand have a low potassium and magnesium status and low urinary excretion of citrate. We measured the changes of urinary citrate excretion and assessed in vivo skeletal muscle metabolism for intracellular-pH, cytosolic-[Mg(2+)] and phosphorylation potential (using the phosphorus magnetic resonance spectroscopy (31)P-MRS) after oral supplementation to hypokaliuric renal stone patients with oral potassium and magnesium salts. The patients comprised four groups: Group 1 (n = 10) control, Group 2 (n = 3), Group 3 (n = 5) and Group 4 (n = 6) supplemented for a month with potassium citrate, potassium citrate plus amino acid chelated magnesium, and potassium-magnesium citrate, respectively. Though urinary citrate excretion was increased in all three supplemented groups, the increases in intracellular-pH, cytosolic-[Mg(2+)] and phosphocreatine (PCr)/beta-ATP were prominent only in Group 3. The increase in PCr/beta-ATP was also observed in Group 4.     

Considerations for brain pH assessment by 31P NMR

Recently in vivo NMR spectroscopy has been used to measure brain pH non-invasively. Both the inorganic orthophosphate (Pi) chemical shift (delta) and the difference between the chemical shifts of phosphocreatine (PCr) and Pi(delta delta PCr-Pi) have been proposed as indicators of brain pH. However, the precise delta of Pi may be difficult to determine under normoxic conditions as is the delta of PCr under hypoxic/ischemic conditions. Ideally one needs a NMR delta parameter that: (1) linearly changes between pH 6.0-8.0, (2) is either relatively unaffected or predictably affected by cations (e.g., Mg2+) other than H+, and that (3) comes from readily observable 31P NMR resonances whose delta's can be accurately assessed under all physiological conditions. Therefore, we undertook a systematic 31P NMR study of the pH and Mg2+ titration curves for 16 phosphorus-containing metabolites observed in brain by 31P NMR. On the basis of the titration curves, the delta delta's for PCr-Pi, phosphoethanolamine (PE)-Pi, and PCr-PE fulfill criteria (1) and (2), but not criterion (3). However, the delta delta of ATP gamma-alpha fulfills all three criteria and potentially provides information on the intracellular Mg2+ concentration.     

Reversal of myo-inositol metabolic level in the left dorsolateral prefrontal cortex of rats exposed to forced swimming test following desipramine treatment: an in vivo localized H-MRS study at 4.7 T

The forced swimming test (FST) is a useful paradigm that is relatively quick and simple to perform and has been utilized to predict antidepressant activity based on learned helplessness as a model of depression. To date, few studies have used proton magnetic resonance spectroscopy (¹H-MRS) to assess antidepressant effects in rats. The purpose of this study was to assess desipramine (DMI) effects on the left dorsolateral prefrontal cortex (DLPFC) of the rats, which were randomly assigned to three groups (control, n=10; FST+saline, n=10; FST+DMI, n=10), using single-voxel localization technique. All ¹H-MRS experiments were performed on a Bruker 4.7-T scanner with 400 mm bore magnet, allowing for acquisition of in vivo ¹H point-resolved spectroscopy spectra (TR/TE=3000/30 ms, number of data points=2048, NEX=512, voxel volume=27 μl, scan time=25 min). Proton metabolites were quantified automatically using LCModel software and were expressed as ratios to total creatine (Cr+PCr). Major target metabolites such as N-acetyl aspartate (NAA)+N-acetylaspartylglutamate (NAAG), glutamate+glutamine (Glu+Gln), glycerophosphorylcholine+phosphorylcholine (GPC+PCho), myo-inositol (mIns) and taurine (Tau) were successfully quantified with Cramer–Rao lower boundary ≤10%. There were significantly higher mIns/(Cr+PCr) and mIns/(NAA+NAAG) ratios in the FST+saline group compared to the control group. In the FST+DMI group, both mIns/(Cr+PCr) and mIns/(NAA+NAAG) ratios were significantly decreased to the level similar to those in the control group. No other metabolite ratios were significantly different among the three groups. Our findings suggest a possible role of altered mIns level within the left DLPFC of the rat model for depression.