Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment

CONTEXT

Persons with lower-extremity peripheral arterial disease (PAD) are often asymptomatic or have leg symptoms other than intermittent claudication (IC).

OBJECTIVE

To identify clinical characteristics and functional limitations associated with a broad range of leg symptoms identified among patients with PAD.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of 460 men and women with PAD and 130 without PAD, who were identified consecutively, conducted between October 1998 and January 2000 at 3 Chicago-area medical centers.

MAIN OUTCOME MEASURES

Ankle-brachial index score of less than 0.90; scores from 6-minute walk, accelerometer-measured physical activity over 7 days, repeated chair raises, standing balance (full tandem stand), 4-m walking velocity, San Diego claudication questionnaire, Geriatric Depression Score Short-Form, and the Walking Impairment Questionnaire.

RESULTS

All groups with PAD had poorer functioning than participants without PAD. The following values are for patients without IC vs those with IC. Participants in the group with leg pain on exertion and rest (n = 88) had a higher (poorer) score for neuropathy (5.6 vs 3.5; P<.001), prevalence of diabetes mellitus (48.9% vs 26.7%; P<.001), and spinal stenosis (20.8% vs 7.2%; P =.002). The atypical exertional leg pain/carry on group (exertional leg pain other than IC associated with walking through leg pain [n = 41]) and the atypical exertional leg pain/stop group (exertional leg pain other than IC that causes one to stop walking [n = 90]) had better functioning than the IC group. The group without exertional leg pain/inactive (no exertional leg pain in individual who walks </=6 blocks per week [n = 28]) and the leg pain on exertion and rest group had poorer functioning than those with IC. Adjusting for age, sex, race, and comorbidities and compared with IC, participants with atypical exertional leg pain/carry on achieved a greater distance on the 6-minute walk (404.3 vs 328.5 m; P<.001) and were less likely to stop during the 6-minute walk (6.8% vs 36%; P =.002). The group with pain on exertion and rest had a slower time for completing 5 chair raises (13.5 vs 11.9 seconds; P =.009), completed the tandem stand less frequently (37.5% vs 60.0%; P =.004), and had a slower 4-m walking velocity (0.80 vs 0.90 m/s; P<.001).

CONCLUSIONS

There is a wide range of leg symptoms in persons with PAD beyond that of classic IC. Comorbid disease may contribute to these symptoms in PAD. Functional impairments are found in every PAD symptom group, and the degree of functional limitation varies depending on the type of leg symptom.

Ionization and self-association of unconjugated bilirubin, determined by rapid solvent partition from chloroform, with further studies of bilirubin solubility

Our studies of equilibrium solubilization of crystals of unconjugated bilirubin (UCB) in buffered aqueous NaCl (1988. J. Lipid Res. 29: 335-348) suggested that the two carboxylic pKa values were 6.8 and 9.3 and the solubility of UCB diacid was 0.1 microM. These data, however, were not ideal, due to possible effects of crystal size, metastability, 96-h incubation times with formation of polar derivatives, impurities in the bilirubin, and imprecision of analyses at low concentrations of UCB ([UCB]). In the present study, designed to determine the pKa values and self-association of UCB, these problems were minimized by solvent partition of UCB from solution in CHCl3 into buffered aqueous NaCl. There was no crystal phase. Equilibrium was attained rapidly (10 min); UCB and CHCl3 were highly purified; and accurate diazo assay of low [UCB] in the aqueous phase, [Bw], was achieved by concentrating the UCB through back-extraction into a small volume of CHCl3. By determining effects on partition rations of varying the [UCB] in the CHCl3 phase, [Bc], we could assess also the self-association of UCB species in the aqueous phase. Partition ratios (P = Bw/Bc) did not differ between initial and repeat extractions, indicating insignificant concentrations of polar UCB derivatives. Similar P ratios were obtained when equilibrium was approached from a supersaturated aqueous phase. At 21-25 degrees C, mu = 0.15, the data (n = 76) fit the equation: log P = log Po + log[1 + 10(pH-A) + 10(2pH-B) + Bc.10(4pH-D)]; the bracketed terms reflect P for H2Bo (diacid), HB- (monoanion), B= (dianion), and (B=)2 dimer, respectively. Computer-fitted values for constants (+/- SD) were: Po = P for H2Bo = 5.79 x 10(-5); A = pK1 = 8.12 +/- 0.23; B = pK1 + pK2 = 16.56 +/- 0.10; pK2 = 8.44 +/- 0.33; D = pk22 + 2(pK1 + pK2) -log(2Po) = 37.64 +/- 0.07, and k22 = 0.26 microM-1 [formation constant of (B=)2 dimer]. In ancillary studies, multiple cycles of direct dissolution of UCB crystals revealed a progressive decrease in aqueous solubility of UCB as fine crystals were removed; this effect was minimal in CHCl3. Unlike in water, moreover, varied UCB crystal forms had similar solubilities in CHCl3, with [Bc] = 1.14 mM at saturation. As determined from [Bc]sat.Po, the aqueous solubility of H2Bo was 66 nM.(ABSTRACT TRUNCATED AT 400 WORDS)

Binding of calcium by organic anions, determined by perturbation of the equilibrium solubility of [14C]calcium oxalate

Confirmation is needed of the reported binding of calcium ions (Ca2+) by bile salts, which is believed to decrease the activity of free calcium ions [Ca2+] available for precipitation of insoluble calcium salts of organic anions in pigment gallstones. We report a new method to determine the association constants (K'f) of calcium for organic anions, from the perturbation by the added anion of the equilibrium solubilization of calcium [14C]oxalate monohydrate crystals (CaOx*). CaOx* crystals were prepared by stepwise conversion of [14C]oxalic acid to its K+ and Ca2+ salts. Structure and purity were confirmed by X-ray diffraction of the crystals. CaOx* was incubated (37 degrees C, under N2) in 0.15 M NaCl in CO2-free deionized H2O at pH 6.3. Dissolution of CaOx*, estimated by radioassay of the 0.22-micron Millipore filtrate, attained equilibrium at 3 days, with K'sp = [Ca2+] * [Ox=] = 2.34 X 10(-8) M2, calculated using known affinity constants for the soluble complexes of NaOx- (K'NaOx = 3.215 M-1) and CaOx (K'CaOx = 195.0 M-1). Keeping total [Na+] = 0.15 M, we added anions that formed soluble complexes with Ca2+. This decreased free [Ca2+], causing more CaOx* to dissolve in amounts related to the concentration of added anion and its K'f for Ca2+. With this method, K'f values for citrate, malonate and malate were similar to the values we determined with the Ca2+ ion electrode, and to published values obtained with the Ca2+ ion electrode and other methods. The sensitivity of the CaOx method permits determination of K'f values with small quantities and low concentrations of the anions and calcium.

Molecular and micellar associations in the pH-dependent stable and metastable dissolution of unconjugated bilirubin by bile salts

Unconjugated bilirubin (UCB) is almost insoluble in water at neutral pH, but appears in normal human gallbladder bile at concentrations up to 35 microM. We therefore determined whether conjugated bile salts could increase the dissolved concentration [( Bt]) of UCB over the pH range 3.0-11.0. Using crystalline UCB, [Bt] was higher with less ordered crystals, with increasing pH and bile salt concentration, and with taurocholate (TC) micelles compared to taurodehydrocholate (TDHC) dimers. Plots of [Bt] verus pH from pH 3.0-9.3 fit the equation, [Bt] = A(1 + K'1/[H]+ + K'1.K'2/[H+]2), where A = [Bt] at pH less than 4.0, and K'1 and K'2 are the two apparent ionization constants of UCB. Estimated pK'1 values in NaCl, TC, and TDHC were 6.8, 6.0, and 5.6, respectively; pK'2 was greater than or equal to 9.3 in each system. Acidification of disodium bilirubinate to pH less than 8.5 produced high, metastable [Bt] in 50 mM TC; this was absent in 0.15 M NaCl, and minor in 50 mM TDHC. In all solutions, maximum [Bt] of 60-65 mM was attained at pH greater than or equal to 10.5. This work helps explain the immense variation among reported [Bt] values, indicates that UCB monoanion predominates at the pH range of bile, and suggests that bile salt monomers, dimers, and micelles enhance the solubility of UCB in bile.

Effects of phenobarbital on bilirubin metabolism and its response to phototherapy in the jaundiced Gunn rat

Jaundiced Gunn rats, treated with phenobarbital (60 mg per kg i.p. for 7 to 10 days) showed 25 and 36% decreases in mean plasma bilirubin levels in two experiments (p less than 0.01). Kinetic studies with tracer 14C-bilirubin revealed that there was no change in bilirubin turnover or total pool size due to phenobarbital, but a 49% increase in the hepatic pool and a 27% decrease in the cutaneous pool of bilirubin. The increase in the hepatic pool accounted for over 90% of the bilirubin lost from the plasma. Such pretreatment with phenobarbital did not alter the decline in plasma bilirubin or total bilirubin pool due to subsequent phototherapy. Phenobarbital followed by phototherapy produced a significantly greater reduction in plasma bilirubin levels than either treatment alone. These studies demonstrate that phenobarbital does decrease plasma bilirubin in Gunn rats primarily by shifting the pigment to the liver, and suggests that combined treatment with phenobarbital and phototherapy might be of value in patients with congenital hyperbilirubinemia due to glucuronyl transferase deficiency.

Bilirubin chemistry, ionization and solubilization by bile salts

Bilirubin is a linear tetrapyrrole whose conformation is affected by internal hydrogen bonds formed between the carboxyl side chains and dipyrromethenone rings. Structural variations include: constitutional isomerism of the vinyl or carboxyethyl side chains, geometric isomerism of the methene bridges, tautomerism of the lactam groups, conformational rotations about the central methylene bridge and ionization of one or both carboxyl groups. Aggregation of the dianion into dimers and multimers may occur. The pKa' values of the two carboxyl groups are affected greatly by the environment and may differ widely in micellar solutions like bile. Solubility of bilirubin in water is less than 1 nM at pH = 7 and about 0.1 microM at pH = 8. Nonetheless, it dissolves poorly in most lipid solvents, except for asymmetrical chloroalkanes. Hydrogen bond-breaking solvents, especially dimethyl sulfoxide, are most effective in solubilizing bilirubin. In bile salt solutions, solubility of bilirubin is well above the concentrations of unconjugated bilirubin found in normal human gallbladder bile, and is impaired by lecithin but unaffected by cholesterol. At physiological pH in bile salt solutions, bilirubin is predominantly in its monoanion form that binds readily to the micelles. In such solutions, addition of physiological concentrations of calcium precipitates calcium bilirubinate, leaving residual bilirubin concentrations of up to 15 microM in 50 mM taurocholate or close to the maximum bilirubin concentrations in normal bile. Studies in which disodium bilirubinate is dissolved in bile salt solutions and pH is adjusted to the physiological range reveal that metastable supersaturation with bilirubin may occur and that a mesophase may also form in the presence of lecithin, akin to that seen with cholesterol.(ABSTRACT TRUNCATED AT 250 WORDS)

Serial observations of angiotensin-converting enzyme and pulmonary function in sarcoidosis

Fifty-six measurements of angiotensin-converting enzyme (ACE) level, diffusing capacity (DLCO), and total lung capacity (TLC) were made in 18 sarcoid patients with a maximum of 25 months of follow-up observation. During spontaneous or corticosteroid-induced changes in disease activity, there was a significant inverse correlation between changes in ACE level and changes in DLCO and between changes in ACE level and changes in TLC. These observations suggest that ACE measurement may be a useful adjunct to pulmonary function tests to follow the course of sarcoidosis and to monitor the effects of corticosteroid therapy on the lung.

Variability of the volume of isoflow

Twenty healthy hospital workers produced maximal expiratory flow-volume curves before and after three vital capacity inhalations of an 80 percent helium and 20 percent oxygen mixture (HE+O2) in the morning and afternoon for four days during one week. Ten healthy trade union apprentices underwent the same tests, twice on one day and again one month later. Measurements made from curves (and their mean coefficients of variation) were: VisoV (105 percent) FVC (3 percent), FEF50% (6 percent), FEF75% (8 percent), the ratio of FEF50% breathing He+O2 to FEF50% breathing air (6 percent), and the ratio of FEF75% breathing He+O2 to FEF75% breathing air (9 percent). Differences among separate observers contributed significantly to the high variability of the VisoV. Diurnal changes and training effects over the week of study were not significant. In conclusion, VisoV is poorly reproducible compared with the FVC and expiratory flow rates at low lung volumes breathing air and He+O2. This should be considered when interpreting results in a given individual.

Increased proportion of active sheep erythrocyte rosette-forming lymphocytes and plasma rosette enhancement in sarcoidosis

We examined blood lymphocyte subpopulations in 20 patients with sarcoidosis, 37 patients with other diseases, and 51 normal subjects. The B-lymphocytes were identified by the presence of surface immunoglobulin or B-lymphocyte-associated antigen. Lymphocytes were also centrifuged with sheep erythrocytes for 5 min at room temperature at 200 g, and rosette formation was assayed immediately (active E-rosette-forming T-lymphocytes) or after 60-min incubation at 4 degrees C (total T-lymphocytes). The B-lymphocytes counts did not differ among the groups. The proportions of total E-rosette-forming T-lymphocytes and active E-rosette-forming T-lymphocytes were increased in the sarcoid patients, whereas absolute counts of both types of E-rosette-forming T-lymphocytes were not different from control counts. Active E-rosette-forming T-lymphocytes showed an inverse correlation with serum concentration of angiotensin-1-converting enzyme, a probable indicator of the disease activity. Incubation of normal lymphocytes with sarcoid plasma increased the proportion of active E-rosette-forming T-lymphocytes. This plasma rosette enhancement was correlated with the number of active E-rosette-forming T-lymphocytes in the blood from which the plasma was separated. These results suggest that a factor in sarcoid plasma affects the number of active E-rosette-forming T-lymphocytes and that high numbers of these cells are associated with disease stability.