Upper extremity impairments, pain and disability in patients with diabetes mellitus

OBJECTIVES

To determine the severity of, and relationships between, upper extremity impairments, pain and disability in patients with diabetes mellitus, and to compare upper extremity impairments in patients with diabetes with non-diabetic controls.

DESIGN

Case-control, cross-sectional design.

SETTING

University-based, outpatient diabetes centre and physical therapy research clinic.

PARTICIPANTS

Two hundred and thirty-six patients with diabetes attending an outpatient diabetes clinic completed the Shoulder Pain and Disability Index (SPADI) questionnaire. A detailed shoulder and hand examination was conducted on a subgroup of 29 volunteers with type 2 diabetes, and 27 controls matched for age, sex and body mass index.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

SPADI score, passive shoulder range of motion (ROM) and strength, grip strength, hand sensation, dexterity and limited joint mobility of the hand.

RESULTS

Sixty-three percent (149/236) of patients with diabetes reported shoulder pain and/or disability [median SPADI score 10.0 (interquartile range 0.0 to 39.6)]. Compared with the control group, the subgroup of patients with diabetes had substantial reductions in shoulder ROM, shoulder muscle strength, grip and key pinch strength (P<0.05). Patients with diabetes had a greater prevalence of decreased sensation (26/27 vs 14/27) and limited joint mobility of the hand (17/27 vs 4/27) compared with the control group. Total SPADI score was negatively correlated (P<0.05) with shoulder ROM (r=-0.42 to -0.74) and strength measures (r=-0.44 to -0.63) in patients with diabetes.

CONCLUSIONS

Upper extremity impairments in this sample of patients with diabetes were common, severe and related to complaints of pain and disability. Additional research is needed to understand the unique reasons for upper extremity problems in patients with diabetes, and to identify preventative treatments.

Pollen-derived low-molecular weight factors inhibit 6-sulfo LacNAc+ dendritic cells' capacity to induce T-helper type 1 responses

BACKGROUND

Evidence is accumulating that the pollen exsudate contains an array of non-allergenic, pro-inflammatory and immunomodulatory substances acting on the innate and adaptive immune system. In this context, pollen-associated E(1)-phytoprostanes (PPE(1)) were shown to licence human monocyte-derived dendritic cells for T-helper type 2 (Th2) polarization of naïve T cells.

OBJECTIVE

This study aims at analysing the impact of pollen-associated lipid mediators on cytokine secretion and maturation of 6-sulfo LacNAc(+) dendritic cells (slanDCs), the most abundant native dendritic cell (DC) in human peripheral blood, and further dissecting the biologically active substance(s) within aqueous pollen extracts.

RESULTS

Aqueous birch pollen extracts dose-dependently inhibited the lipopolysaccharide (LPS)-induced IL-12 p70 production, while the levels of IL-6 remained unaffected. PPE(1) inhibited secretion of both IL-12 p70 and IL-6. Aqueous pollen extracts, but not PPE(1) or F(1)-phytoprostanes significantly reduced the LPS-induced surface expression of the maturation markers CD80, CD83, CD40 and CCR-7, an effect that was independent of proteins and that was still present in a 3 kDa cut-off fraction of the pollen extract. These effects were observed irrespective of the atopy status of the donors. Finally, slanDCs exposed to aqueous pollen extracts were impaired in eliciting an IFN-gamma response in naïve CD4(+) T cells.

CONCLUSION

Our data show that slanDCs, a subset of human blood DCs with constitutively high potency to induce Th1 responses, are susceptible to the Th2 polarizing effect of low molecular weight, non-protein factors derived from pollen.

DONGLE and DEFECTIVE IN ANTHER DEHISCENCE1 lipases are not essential for wound- and pathogen-induced jasmonate biosynthesis: redundant lipases contribute to jasmonate formation

Lipases are involved in the generation of jasmonates, which regulate responses to biotic and abiotic stresses. Two sn-1-specific acyl hydrolases, DEFECTIVE IN ANTHER DEHISCENCE1 (DAD1) and DONGLE (DGL), have been reported to be localized in plastids and to be essential and sufficient for jasmonate biosynthesis in Arabidopsis (Arabidopsis thaliana) leaves. Here, we show that levels of 12-oxo-phytodienoic acid (OPDA) and jasmonic acid in three different DGL RNA interference lines and the dad1 mutant were similar to wild-type levels during the early wound response as well as after Pseudomonas infection. Due to the lack of sn-2 substrate specificity, synthesis of dinor OPDA was not expected and also not found to be affected in DGL knockdown and DGL-overexpressing lines. As reported, DAD1 participates in jasmonate formation only in the late wound response. In addition, DGL protein was found to be localized in lipid bodies and not in plastids. Furthermore, jasmonate levels in 16 additional mutants defective in the expression of lipases with predicted chloroplast localization did not show strong differences from wild-type levels after wounding, except for a phospholipase A (PLA) PLA-Igamma1 (At1g06800) mutant line that displayed diminished wound-induced dinor OPDA, OPDA, and jasmonic acid levels. A quadruple mutant defective in four DAD1-like lipases displayed similar jasmonate levels as the mutant line of PLA-Igamma1 after wounding. Hence, we identify PLA-Igamma1 as a novel target gene to manipulate jasmonate biosynthesis. Our results suggest that, in addition to DAD1 and PLA-Igamma1, still unidentified enzymes with sn-1 and sn-2 hydrolase activity are involved in wound- and pathogen-induced jasmonate formation, indicating functional redundancy within the lipase family.

Energy expenditure and energy intake - Guidelines on Parenteral Nutrition, Chapter 3

The energy expenditure (24h total energy expenditure, TEE) of a healthy individual or a patient is a vital reference point for nutritional therapy to maintain body mass. TEE is usually determined by measuring resting energy expenditure (REE) by indirect calorimetry or by estimation with the help of formulae like the formula of Harris and Benedict with an accuracy of +/-20%. Further components of TEE (PAL, DIT) are estimated afterwards. TEE in intensive care patients is generally only 0-7% higher than REE, due to a low PAL and lower DIT. While diseases, like particularly sepsis, trauma and burns, cause a clinically relevant increase in REE between 40-80%, in many diseases, TEE is not markedly different from REE. A standard formula should not be used in critically ill patients, since energy expenditure changes depending on the course and the severity of disease. A clinical deterioration due to shock, severe sepsis or septic shock may lead to a drop of REE to a level only slightly (20%) above the normal REE of a healthy subject. Predominantly immobile patients should receive an energy intake between 1.0-1.2 times the determined REE, while immobile malnourished patients should receive a stepwise increased intake of 1.1-1.3 times the REE over a longer period. Critically ill patients in the acute stage of disease should be supplied equal or lower to the current TEE, energy intake should be increased stepwise up to 1.2 times (or up to 1.5 times in malnourished patients) thereafter.

Muscle imbalance and reduced ankle joint motion in people with hammer toe deformity

BACKGROUND

Multiple factors may contribute to hammer toe deformity at the metatarsophalangeal joint. The purposes of this study were to (1) compare the ratio of toe extensor/flexor muscle strength in toes 2-4 among groups with and without hammer toe deformity, (2) to determine correlations between the ratio of toe extensor/flexor muscle strength in toes 2-4, and metatarsophalangeal joint deformity (3) to determine if other clinical measures differ between groups and if these measures are correlated with metatarsophalangeal joint angle.

METHODS

Twenty-seven feet with visible hammer toe deformity and 31 age matched feet without hammer toe deformity were tested. Toe muscle strength was measured using a dynamometer and the ratio of toe extensor muscle strength to flexor muscle strength was calculated. Metatarsophalangeal joint angle was measured from a computerized tomography image. Ankle and subtalar joint range of motion, and tibial torsion were measured using goniometry.

FINDINGS

Extensor/flexor toe muscle strength ratio was 2.3-3.0 times higher in the hammer toe group compared to the non-hammer toe group, in toes 2-4. The ratios of extensor/flexor toe muscle strength for toes 2-4 and metatarsophalangeal joint angle were highly correlated (r=0.69-0.80). Ankle dorsiflexion and metatarsophalangeal joint angle were negatively correlated for toes 2-4 (r=-0.38 to -0.56) as were eversion and metatarsophalangeal joint angle.

INTERPRETATION

These results provide insight into potential risk factors for the development of hammer toe deformity. Additional research is needed to determine the causal relationship between hammer toe deformity and the ratio of toe extensor/flexor muscle strength in toes 2-4.

Singlet oxygen is the major reactive oxygen species involved in photooxidative damage to plants

Reactive oxygen species act as signaling molecules but can also directly provoke cellular damage by rapidly oxidizing cellular components, including lipids. We developed a high-performance liquid chromatography-electrospray ionization-tandem mass spectrometry-based quantitative method that allowed us to discriminate between free radical (type I)- and singlet oxygen ((1)O(2); type II)-mediated lipid peroxidation (LPO) signatures by using hydroxy fatty acids as specific reporters. Using this method, we observed that in non-photosynthesizing Arabidopsis (Arabidopsis thaliana) tissues, nonenzymatic LPO was almost exclusively catalyzed by free radicals both under normal and oxidative stress conditions. However, in leaf tissues under optimal growth conditions, (1)O(2) was responsible for more than 80% of the nonenzymatic LPO. In Arabidopsis mutants favoring (1)O(2) production, photooxidative stress led to a dramatic increase of (1)O(2) (type II) LPO that preceded cell death. Furthermore, under all conditions and in mutants that favor the production of superoxide and hydrogen peroxide (two sources for type I LPO reactions), plant cell death was nevertheless always preceded by an increase in (1)O(2)-dependent (type II) LPO. Thus, besides triggering a genetic cell death program, as demonstrated previously with the Arabidopsis fluorescent mutant, (1)O(2) plays a major destructive role during the execution of reactive oxygen species-induced cell death in leaf tissues.

Response of neutron detectors to high-energy mixed radiation fields

Radiation protection around CERN's high-energy accelerators represents a major challenge due to the presence of complex, mixed radiation fields. Behind thick shielding neutrons dominate and their energy ranges from fractions of eV to about 1 GeV. In this work the response of various portable detectors sensitive to neutrons was studied at CERN's High-Energy Reference Field Facility (CERF). The measurements were carried out with conventional rem counters, which usually cover neutron energies up to 20 MeV, the Thermo WENDI-2, which is specified to measure neutrons up to several GeV, and a tissue-equivalent proportional counter. The experimentally determined neutron dose equivalent results were compared with Monte Carlo (MC) simulations. Based on these studies field calibration factors can be determined, which result in a more reliable estimate of H*(10) in an unknown, but presumably similar high-energy field around an accelerator than a calibration factor determined in a radiation field of a reference neutron source.

Tendon Achilles lengthening for the treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait

The purposes of this study were to determine the effects of tendon Achilles lengthening (TAL) on ambulatory plantar pressures and ankle range of motion, moment, and power, and to determine whether changes in forefoot pressure after treatment of a neuropathic ulcer are related to changes in ankle dorsiflexion range of motion (DFROM) or plantar flexor (PF) power during gait. Pressure and gait tests were performed before treatment, and at 3 weeks and 8 months after treatment in two randomly assigned groups of subjects with diabetes, equinus deformity, and a neuropathic forefoot ulcer treated with TAL and total contact casting (TAL group, n=14), or total contact casting alone (TCC group, n=14). The TAL group had an initial decrease in forefoot peak pressure (PP) (27%), forefoot pressure-time integral (PTI) (42%), PF moment (53%), and PF power (65%), along with an initial increase in rear foot PP (34%), rear foot PTI (48%), and DFROM (74%). Post-surgical changes in rear foot pressure and DFROM were maintained up to 8 months after treatment with TAL, whereas forefoot pressure and PF moment and power increased significantly. Changes in forefoot pressure after treatment in either group were correlated with changes in PF power (r=0.45-0.60), but not with changes in DFROM during gait (r=-0.02-0.08). Results suggest TAL causes a temporary reduction in forefoot pressure primarily by reducing PF power during gait. The initial decrease in forefoot pressure, followed by progressive reloading of forefoot tissues as PF muscles regain strength after TAL, may help reduce the risk of ulcer recurrence in patients with diabetes.

Novel Award 2002. Comparison of physical activity and cumulative plantar tissue stress among subjects with and without diabetes mellitus and a history of recurrent plantar ulcers

OBJECTIVES

To compare the amount of weight-bearing activity and estimates of cumulative plantar tissue stress between subjects with and without diabetes mellitus and a history of recurrent plantar ulcers.

DESIGN

Cross-sectional study with matched groups.

BACKGROUND

Weight-bearing activity among individuals with diabetes is likely to influence the amount of mechanical trauma accumulated by plantar tissues, yet activity levels have not been accounted for in previous measurements of plantar tissue stress or predictions of plantar tissue injury.

METHODS

Study groups included subjects with diabetes mellitus and peripheral neuropathy, either with or without a history of recurrent plantar ulcers, and non-diabetic control subjects (n=10 per group). Pressure on the plantar foot was assessed as subjects walked at their preferred speed in the shoes they reported wearing most often each day. Physical activity was monitored over seven consecutive days using an accelerometer. The product of mean daily strides and forefoot pressure-time integral was used to estimate daily cumulative stress on the plantar forefoot.

RESULTS

Subjects with diabetes and a history of recurrent plantar ulcers were 46% less active than subjects without diabetes (mean (SD)=2727 (1345) versus 5037 (2624) strides/day, P=0.04), and accumulated 41% less daily stress on the forefoot than non-diabetic and diabetic control subjects without a history of plantar ulcers (mean (SD)= 210 (134) versus 354 (118) and 354 (148) MPas/day respectively, P=0.03).

CONCLUSIONS

Subjects with diabetes and a history a previous ulcers may be susceptible to plantar tissue injury even at relatively low levels of cumulative tissue stress.

RELEVANCE

Changes in weight-bearing activity following plantar tissue injury in patients with diabetes may influence plantar tissue adaptation and the risk of ulcer recurrence.

Monitoring in-shoe plantar pressures, temperature, and humidity: reliability and validity of measures from a portable device

OBJECTIVE

To investigate the reliability and validity of measures obtained from a portable electronic device used to monitor changes in plantar pressure, temperature, and humidity that occur within the shoe during prolonged activity.

DESIGN

Descriptive study comparing electronic sensor output with criterion values.

SETTINGS

Indoor level walkway for pressure data; uncontrolled, outdoor environment for step count data; enclosed environmental control chamber for humidity and temperature data.

PARTICIPANTS

Convenience sample of 4 healthy, sensate subjects.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Correlations between sensor output and criterion measures were determined for pressure and temperature data. The absolute differences between sensor output and criterion values of temperature, humidity, and step count were also determined.

RESULTS

Pressure measurements from electronic sensors correlated highly with criterion values (r > or =.82), both before and after prolonged use. Relative humidity sensor output were within 5% of hygrometer values. In-shoe temperature data correlated highly with criterion values (r > or =.99), and differed from known temperatures by.50 degrees +/-.84 degrees C and.96 degrees +/- 1.56 degrees C at the forefoot and heel, respectively. Electronic step counts recorded at the central forefoot were within 1 step of visual step counts. Pressure tracings obtained from the device during different weight-bearing activities revealed qualitatively distinct pressure patterns.

CONCLUSION

The device provides valid and reliable measures of in-shoe plantar pressures, temperature, and humidity during prolonged activity.

Precision and accuracy of computed tomography foot measurements

OBJECTIVE

To test the accuracy and precision of computed tomography (CT) imaging for describing the 3-dimensional structure of the foot in patients with diabetes mellitus and peripheral neuropathy.

DESIGN

Experimental, test-retest.

SETTING

Clinical CT scanner at a local hospital.

SPECIMENS

Two tissue-equivalent phantoms and 6 cadaver feet.

MAIN OUTCOME MEASURES

Measurements taken from CT data of phantoms and cadaver feet were compared with physical (caliper) measurements. The feasibility of creating a computer-aided design/rapid prototyping 3-dimensional model from CT data was assessed by using 1 cadaver foot.

RESULTS

No bias was found for phantom or cadaver CT measurements compared with caliper measurements. The mean difference between repeat scans of cadaver feet (1 observer) was 0.1 +/- 0.8 mm and between observers, 0.4 +/- 0.8 mm. Comparing caliper measurements of the rapid prototype model and actual foot measurements revealed an error of 0.3 +/- 0.4 mm.

CONCLUSION

CT-based 3-dimensional imaging produced accurate and precise foot measurements, enabling description of internal and external structures. This capability will be coupled with plantar pressure measurements to improve our understanding and treatment of foot ulcers in people with diabetes.

In-shoe multisensory data acquisition system

Patients with diabetes and peripheral neuropathy are susceptible to unnoticed trauma on the foot that can cause skin breakdown. We have designed an electronic system in a shoe that monitors temperature, pressure, and humidity, storing the data in a battery-powered device for later uploading to a host computer for data analysis. The pressure sensors are located at the heel, and under three metatarsal heads. Temperature sensors are located under the medial metatarsal head and under the heel. The humidity sensor is located in the toe of the shoe. Correlations of data from pressure sensors with known values were high (r > 0.85), even after extended use. Although data currently are being collected for descriptive purposes, the design potentially can be used to provide feedback to patients.

Accuracy and reliability testing of a portable soft tissue indentor

We have designed, built, and tested a portable indentor device that allows us to determine force/displacement (F/D) measurements on soft tissue in a clinical or research setting. The indentor system consists of a load cell mounted on a three-dimensional measurement device (Metrecom). The output of the load cell and the Metrecom are recorded and analyzed by software running on a notebook computer. The displacement calibration of the Metrecom gave an average error = 0.005 mm [standard deviation (SD) = 0.062)]. The force calibration of the load cell resulted in an average error = 0.022 N (SD = 0.049) and a linearity of 1.0062 (R2 = 0.9998). The indentor device was tested on six different human soft tissues by two different investigators. The interreliabilities and intrareliabilities were 0.99 [interclass correlation (ICC)] indicating that the results were repeatable by more than one investigator. F/D measurements from indentor testing on two materials were comparable to values measured using an Instron device (5.34 versus. 5.52 N/mm, and 0.98 versus 1.04 N/mm). The device was used to measure the soft tissue characteristics on the plantar surface of the foot of one subject. These data were used to calculate the effective Young's modulus for the tissue using equations derived by Zheng et al. [1] and indicated a wide range of values dependent upon the portion of the F/D curve used. All results indicate data from this portable indentor device are reliable, accurate, and sensitive enough to identify mechanical properties of human tissues.

Analysis of oxidative stress and wound-inducible dinor isoprostanes F(1) (phytoprostanes F(1)) in plants

Isoprostanes F(2) are arachidonate autoxidation products in mammals that have been shown to be induced during several human disorders associated with enhanced free-radical generation. Isoprostanes F(2) represent not only extremely reliable markers of oxidative stress in vivo, but they also exert potent biological effects. Therefore, it has been postulated that isoprostanoids are mediators of oxidant injury in vivo. Higher plants, however, do not synthesize arachidonic acid or isoprostanes. Here we show that a series of isoprostane F(2) analogs termed phytoprostanes F(1) (previously dinor isoprostanes F(1)) are formed by an analogous pathway from alpha-linolenate in plants. High-performance liquid chromatography and gas chromatography-mass spectrometry methods using [(18)O](3)phytoprostanes F(1) as internal standard have been developed to quantify phytoprostanes F(1). In fresh peppermint (Mentha piperita) leaves, phytoprostanes F(1) were found in free form (76 ng/g of dry weight) and at about 150-fold higher levels esterified in lipids. It is notable that these levels of phytoprostanes F(1) are more than two orders of magnitude higher than the basal levels of isoprostanes F(2) in mammalian tissues. Furthermore, wounding, as well as butyl hydroperoxide or cupric acetate stress triggered a dramatic increase of free and esterified phytoprostanes F(1). Thus phytoprostanes F(1) may represent a sensitive measure of oxidative damage in plants similar to isoprostanes in mammals. However, one of the most exciting issues to be clarified is the possibility that linolenate-derived phytoprostanes F(1) exert biological activities in plants and/or animals.

Relationships between plantar flexor muscle stiffness, strength, and range of motion in subjects with diabetes-peripheral neuropathy compared to age-matched controls

STUDY DESIGN

Descriptive study to compare relationships between muscle performance measures in 2 subject groups.

OBJECTIVES

To determine the relationships between plantar flexor (PF) muscle stiffness, strength (concentric peak torque), and dorsiflexion (DF) range of motion (ROM) in subjects with diabetes who have peripheral neuropathy (n = 17, 10 men, 7 women; age = 58 +/- 11 years) and age-matched controls (n = 17, 10 men, 7 women; age = 62 +/- 6 years).

BACKGROUND

The relationships between muscle stiffness, strength, and joint ROM have not been clearly established. Furthermore, the effect of neuromuscular pathology on these relationships is unknown.

METHODS AND MEASURES

PF stiffness and strength measurements were obtained with an isokinetic dynamometer. DF ROM was measured with a goniometer. A Pearson correlation matrix was constructed for each subject group using stiffness, strength, and ROM variables. The percent contribution of passive torque to total torque was computed at 2 joint angles.

RESULTS

In subjects with diabetes and peripheral neuropathy (DM-PN) peak concentric PF torque was positively correlated with passive torque at 5 degrees DF (r = 0.77), Stiffness #1 (r = 0.58), and Stiffness #2 (r = 0.50). The percentage of passive PF torque at 5 degrees DF was greater in subjects with DM-PN, compared to control subjects (29.3 +/- 9.4% versus 12.6 +/- 5.9%).

CONCLUSIONS

The positive correlation between PF stiffness and strength, and the greater percentage of passive PF torque in subjects with DM-PN suggest that patients with decreased strength may use passive torque to maximize total torque. Therefore, treatment methods designed to decrease stiffness should be used cautiously.

Effect of plantar flexor muscle stiffness on selected gait characteristics

Although plantar flexor muscle strength is known to affect gait characteristics, the effect of plantar flexor (PF) muscle stiffness on gait is unknown. The purpose of this study was to determine the effect of PF muscle stiffness, in addition to PF strength, on the gait characteristics of subjects with diabetes and peripheral neuropathy (DM & PN) and age-matched controls. Thirty-four subjects were tested (17 DM & PN, 17 controls), 10 males and seven females in each group. PF muscle strength (concentric peak torque) explained a significant amount of variance in all gait variables (20-37%). Passive stiffness added a unique contribution to plantar flexor peak moment and walking speed (10-11%). Plantar flexor stiffness, in addition to strength, may be an important factor contributing to gait characteristics. Treatment techniques designed to preserve or increase stiffness may be indicated for patients with limited PF strength.

Passive ankle stiffness in subjects with diabetes and peripheral neuropathy versus an age-matched comparison group

BACKGROUND AND PURPOSE

Patients with diabetes mellitus and peripheral neuropathy (DM and PN) often complain of joint stiffness. Although stiffness may contribute to some of the impairments and functional limitations found in these patients, it has not been quantified in this population. The purpose of this study was to quantify and compare passive ankle stiffness and dorsiflexion (DF) range of motion in subjects with DM and PN versus an age-matched comparison group.

SUBJECTS

Thirty-four subjects were tested (17 subjects with DM and PN and 17 subjects in an age-matched comparison group). There were 10 male subjects and 7 female subjects in each group.

METHODS

A Kin-Com dynamometer was used to measure passive plantar flexor torque as each subject's ankle was moved from plantar flexion into dorsiflexion at 60(/s. The following variables were compared using a Student t test: initial angle (angle of onset of plantar flexor torque), maximal dorsiflexion angle, plantar flexor muscle excursion (difference between initial angle and maximal dorsiflexion angle), slope of the first half of the plantar flexor torque curve (stiffness 1 measurement), and slope of the second half of the plantar flexor torque curve (stiffness 2 measurement).

RESULTS

The subjects with DM and PN had smaller maximal dorsiflexion angles and less plantar flexor muscle excursion than the comparison group. There was no difference in initial angle, stiffness 1 measurement, or stiffness 2 measurement.

CONCLUSION AND DISCUSSION

Although the subjects with DM and PN had less dorsiflexion range of motion than did the comparison group, there was no difference in stiffness between the groups. This finding suggests that people with DM and PN have "short" versus "stiff" plantar flexor muscles.

Formation of isoprostane F(2)-like compounds (phytoprostanes F(1)) from alpha-linolenic acid in plants

Isoprostanes F(2) are biologically active prostaglandin F(2)-like compounds formed by free radical-catalyzed oxidation of arachidonic acid (C20:4). Here, we show that a series of dinor isoprostanes F(1), which we term phytoprostanes F(1) (PPF(1)s), are formed by nonenzymatic oxidation of linolenate (C18:3) in plants. Identification and quantification of PPF(1)s were achieved by a negative ion chemical ionization gas chromatography-mass spectrometry method using oxygen 18-labeled PPF(1)s as internal standards. PPF(1)s were found in leaves, flowers, and roots of taxonomically distinct plant species at concentrations ranging from 43 to 1380 ng/g of dry weight. In addition, esterified PPF(1)s were found at 10- to 150-fold higher concentrations. During the drying and storage of various plant organs, endogenous PPF(1) levels increased dramatically by 15- to 263-fold. Because the structurally related prostaglandin F(2alpha) and isoprostanes F(2) exert potent biological activities (i.e., broncho- and vasoconstriction) in the nanomolar range, PPF(1)s could potentially exert similar biological activities. Notably, fresh birch pollen, which can easily be inhaled, contains exceedingly high concentrations (32,440 ng/g) of free PPF(1)s.

Effects of a tendo-Achilles lengthening procedure on muscle function and gait characteristics in a patient with diabetes mellitus

STUDY DESIGN

Case report with repeated measures.

OBJECTIVES

To describe the effects of a tendo-Achilles lengthening (TAL) and total contact casting (TCC) on wound healing, motion, plantar pressure, and function in a patient with diabetes mellitus, peripheral neuropathy, neuropathic ulcer, and limited dorsiflexion range of motion (DFROM).

BACKGROUND

Limited DFROM has been associated with increased forefoot pressures and skin breakdown. A TAL was expected to increase DFROM and reduce forefoot pressures during walking, but the influence on muscle performance and function was unknown.

METHODS AND MEASURES

The patient was a 42-year-old man with a 20-year history of type 1 diabetes (NIDDM) and a recurrent neuropathic plantar ulcer. Outcome measures were DFROM, isokinetic plantar flexor muscle peak torque, in-shoe and barefoot peak plantar pressure, physical performance test (PPT) score, and peak ankle and hip moments during walking obtained from an automated gait analysis. All tests were completed pre-TAL, 8 weeks post-TAL (after immobilization in a TCC), and 7 months post-TAL.

RESULTS

The wound healed in 40 days. The TAL resulted in a sustained increase in DFROM (0 to 18 degrees). Plantar flexor peak torque was reduced by 21% 8 weeks after the TAL compared with the torque before surgery but recovered fully at 7 months. Seven months following TAL, in-shoe forefoot peak plantar pressure was reduced by 55%, barefoot pressure decreased by 14%, PPT score increased by 24%, peak ankle plantar flexor moment remained decreased by 30%, and the peak hip flexor moment increased by 41% during walking.

CONCLUSION

For this patient, a TAL resulted in short-term deficits in peak plantar flexor torque, but a 7-month follow-up showed improvements in ankle DFROM, walking ability, and a decrease in forefoot in-shoe peak plantar pressure.

Timing of peak plantar pressure during the stance phase of walking. A study of patients with diabetes mellitus and transmetatarsal amputation

High plantar pressures contribute to skin breakdown in patients with diabetes mellitus and peripheral neuropathy. The primary purpose of this study was to determine the point during the stance phase of walking that corresponds with forefoot peak plantar pressures. Results indicate that peak plantar pressures occurred at 80% +/- 5% of the stance phase of gait in subjects with diabetes and transmetatarsal amputation, as well as in control subjects. Improved methods of footwear design or walking strategies proposed to patients should focus on the demands of the foot during the late stance phase of walking in order to increase available weightbearing area or to decrease forces, which will minimize plantar pressures and reduce trauma to the neuropathic foot.

Assessment of the diabetic foot using spiral computed tomography imaging and plantar pressure measurements: a technical report

Persons with diabetes mellitus (DM) and peripheral neuropathy are at high risk for skin breakdown due to unnoticed excessive pressures to the plantar foot during walking. We developed methods that combined spiral x-ray computed tomography (SXCT) imaging and plantar pressure analysis to quantify internal foot structure and external pressure during plantar loading. Methods were tested using a subject with DM who had a plantar ulcer, and a healthy control. SXCT measurements were within 2 mm of truth and SXCT plantar recordings were within 6.5% of walking trials. Hammer toe deformity (second toe), severe atrophy of the intrinsic muscles and less contact area during plantar loading, and a peak plantar pressure three times greater at the site of the ulcer were measured in the diabetic foot as compared with the healthy control. This preliminary investigation suggests that these methods are accurate for structural and pressure measurements of diabetic and healthy feet.

Application of plantar pressure assessment in footwear and insert design

This clinical perspective describes the application of plantar pressure assessment in footwear and insert design. First, the rationale and evidence for using pressure assessment to assist in the design of footwear for patients with diabetes is described. I discuss 2 important measures obtained from pressure assessment: peak pressure, because it represents the magnitude of potential mechanical stresses that can contribute to skin breakdown, and contact area, because this identifies the treatment areas. Using measures obtained from pressure assessment, guidelines are presented to maximize contact area of the insert to the foot and reduce highest peak pressures on the skin, with the goal of preventing skin breakdown. Second, a rationale and guidelines are presented for the application of plantar pressure assessment in the evaluation and design of footwear for people without impairments (i.e., the general public). Finally, future applications of pressure assessment to improve the design and fit of shoes are discussed. Benefits and limitations of using pressure assessment to assist in footwear design are addressed throughout.

Analyses of prostaglandin D2 metabolites in urine: comparison between enzyme immunoassay and negative ion chemical ionisation gas chromatography-mass spectrometry

Measurements of the prostaglandin (PGD2) metabolite 9 alpha, 11 beta-PGF2 in unextracted urine performed by enzyme immunoassay (EIA) were compared with values obtained by negative chemical ionisation gas chromatography-mass spectrometry (NCI GC-MS). Values determined by NCI GC-MS were in the same range but consistently lower than those obtained by EIA, suggesting that other endogenous compounds could be contributing to the immunoreactivity. Isoprostanes were generated by autoxidation of arachidonic acid and the 9 alpha, 11 beta-PGF2 antibody demonstrated less than 0.7% crossreactivity to the mix, making it unlikely that isoprostanes in urine interfere with quantification of 9 alpha, 11 beta-PGF2 by EIA. This was further supported by the 70% reduction in immunoreactive material measured in urine after three days treatment in a healthy volunteer with the cyclooxygenase inhibitor ibuprofen. Purification of urine samples by reverse phase high-performance liquid chromatography (HPLC) revealed the presence of two immunoreactive compounds in addition to 9 alpha, 11 beta-PGF2. The compounds were identified as dinor compounds by NCI GC-MS. One of the compounds was identical to 9 alpha, 11 beta-2,3-dinor-PGF2 which was generated by beta-oxidation of 9 alpha, 11 beta-PGF2 and identified by electron impact (EI)-GC-MS. In conclusion, urinary 9 alpha, 11 beta-PGF2 concentrations measured by EIA represent the sum of 9 alpha, 11 beta-PGF2 and two isomers of its dinor metabolite. Thus, the direct EIA is fast, sensitive and sufficiently specific to monitor activation of the PGD2 pathway, thereby providing a valuable clinical tool to assess the status of mast cell activation in vivo.

Involvement of the octadecanoid pathway and protein phosphorylation in fungal elicitor-induced expression of terpenoid indole alkaloid biosynthetic genes in catharanthus roseus

Two key genes in terpenoid indole alkaloid biosynthesis, Tdc and Str, encoding tryptophan decarboxylase and strictosidine synthase, respectively, are coordinately induced by fungal elicitors in suspension-cultured Catharanthus roseus cells. We have studied the roles of the jasmonate biosynthetic pathway and of protein phosphorylation in signal transduction initiated by a partially purified elicitor from yeast extract. In addition to activating Tdc and Str gene expression, the elicitor also induced the biosynthesis of jasmonic acid. The jasmonate precursor alpha-linolenic acid or methyl jasmonate (MeJA) itself induced Tdc and Str gene expression when added exogenously. Diethyldithiocarbamic acid, an inhibitor of jasmonate biosynthesis, blocked both the elicitor-induced formation of jasmonic acid and the activation of terpenoid indole alkaloid biosynthetic genes. The protein kinase inhibitor K-252a abolished both elicitor-induced jasmonate biosynthesis and MeJA-induced Tdc and Str gene expression. Analysis of the expression of Str promoter/gusA fusions in transgenic C. roseus cells showed that the elicitor and MeJA act at the transcriptional level. These results demonstrate that the jasmonate biosynthetic pathway is an integral part of the elicitor-triggered signal transduction pathway that results in the coordinate expression of the Tdc and Str genes and that protein kinases act both upstream and downstream of jasmonates.

Use of computed tomography and plantar pressure measurement for management of neuropathic ulcers in patients with diabetes

BACKGROUND AND PURPOSE

Total contact casting is effective at healing neuropathic ulcers, but patients have a high rate (30%-57%) of ulcer recurrence when they resume walking without the cast. The purposes of this case report are to describe how data from plantar pressure measurement and spiral x-ray computed tomography (SXCT) were used to help manage a patient with recurrent plantar ulcers and to discuss potential future benefits of this technology.

CASE DESCRIPTION

The patient was a 62-year-old man with type 1 diabetes mellitus (DM) of 34 years' duration, peripheral neuropathy, and a recurrent plantar ulcer. Although total contact casting or relieving weight bearing with crutches apparently allowed the ulcer to heal, the ulcer recurred 3 times in an 18-month period. Spiral x-ray computed tomography and simultaneous pressure measurement were conducted to better understand the mechanism of his ulceration.

OUTCOMES

The patient had a severe bony deformity that coincided with the location of highest plantar pressures (886 kPa). The results of the SXCT and pressure measurement convinced the patient to wear his prescribed footwear always, even when getting up in the middle of the night. The ulcer healed in 6 weeks, and the patient resumed his work, which required standing and walking for 8 to 10 hours a day.

DISCUSSION

Following intervention, the patient's recurrent ulcer healed and remained healed for several months. Future benefits of these methods may include the ability to define how structural changes of the foot relate to increased plantar pressures and to help design and fabricate optimal orthoses.

Evidence for the formation of dinor isoprostanes E1 from alpha-linolenic acid in plants

The free radical oxidation of arachidonic acid is known to generate complex metabolites, termed isoprostanes, that share structural features of prostaglandins and exert potent receptor-mediated biological activities. In the present study, we show that alpha-linolenic acid can undergo a similar oxidation process, resulting in a series of isomeric dinor isoprostanes E1. E-ring dinor isoprostane formation from linolenate was found to be catalyzed by soybean lipoxygenase. The main enzymatic products were 13- and 9-hydroperoxylinolenate but in addition, two dinor isoprostane E1 regioisomers were formed with a yield of 0.31%. Identification and quantification of two dinor isoprostane E1 regioisomers in plant cell cultures was achieved by a negative chemical ionization gas chromatography-mass spectrometry method using [18O]dinor isoprostanes E1 as internal standards. Endogenous levels of these compounds were determined in four taxonomically distant plant species and found to be in the range of 4.5 to 60.9 ng/g of dry weight. Thus analogous pathways in animals and plants exist, each leading to a family of prostaglandin-like compounds derived from polyunsaturated fatty acids. It remains to be shown whether the dinor isoprostanes exert biological activities in plants as has been demonstrated for their C20 congeners in mammals.

Radically novel prostaglandins in animals and plants: the isoprostanes

Animal prostaglandins and plant jasmonates are well-known enzymatically formed cyclopentanoic lipids that have regulatory functions and serve as inducible mediators of host defense reactions. A novel group of prostaglandin-like compounds, the isoprostanes, generated in animals and plants by a nonenzymatic, free radical-catalyzed process, are now suspected to be mediators of oxidant injury in vivo.

Transport of arachidonic acid across the neutrophil plasma membrane via a protein-facilitated mechanism

Arachidonic acid is the rate-limiting substrate in the biosynthesis of leukotrienes in activated neutrophils. Liberation of arachidonate from intracellular membranes and uptake of exogenous arachidonate are the two principal mechanisms by which the cell can increase the level of this substrate. We investigated arachidonate uptake and export by using intact polymorphonuclear neutrophils and inside-out plasma membrane vesicles thereof. Here we show that the cellular uptake of arachidonate is energy dependent with an energy of activation (EA) of 10.0 kcal/mol and half-saturated at an arachidonate concentration of 4.8 nmol/mg of cell protein. Protein-facilitated transport of arachidonate across the plasma membrane in either direction is sensitive to proteases, chemical protein modifying reagents, anion transport inhibitors, and, most notably, toward several structurally unrelated leukotriene B4 receptor antagonists with IC50 values in the range of 16-44 microM. The inhibitors did not inhibit the diffusional uptake of methyl arachidonate into neutrophils and inside-out plasma membrane vesicles, indicating that a transport protein is required for the rapid uptake of the free acid but not for the uptake of the ester. Other long-chain fatty acids did compete with the uptake of arachidonate in both assay systems, whereas leukotriene B4 did not. This study documents a novel protein-facilitated transport mechanism for arachidonate in neutrophils, potentially involved in transcellular eicosanoid biosynthesis and sPLA2-mediated arachidonate signaling in neutrophils.

A "step-to" gait decreases pressures on the forefoot

Physical therapists use various gait training strategies to reduce stress on the lower extremities, but we could find no description or evaluation of the step-to gait using a cane. The purpose of this study was to evaluate the effect of a step-to gait pattern and a cane on peak plantar pressures on the forefoot and the heel. Ten healthy subjects were evaluated (five females, five males, mean age = 24.6 +/- 4.9 years). In addition, one subject with peripheral neuropathy was tested to determine if a patient could be trained to use the step-to walking pattern and show similar results. All subjects were instructed in four walking conditions; step-to with and without a cane and step-through with and without a cane. Walking speed during the step-through pattern (normal walking) was matched to the speed of the step-to pattern. For the 10 healthy subjects, peak plantar pressures and walking speed of each of the four conditions were compared using a 2 x 2 repeated measures analysis of variance. One factor was gait pattern and one factor was use of a cane. Peak plantar pressures decreased an average of 53% on the forefoot but increased an average of 14% on the heel when subjects walked using step-to gait compared with a step-through gait. There was no effect due to use of a cane or walking speed between the conditions. The patient with peripheral neuropathy demonstrated a similar pattern but greater magnitude of changes compared with the healthy subjects. The foot initiating the step-to pattern showed a reduction in peak plantar pressures on the forefoot, probably because the foot remained flat during stance phase and a large push-off was not required. The step-to pattern, however, results in a slower and less symmetrical gait. The use of a step-to gait may be beneficial for patient populations that need to reduce plantar pressures on the forefoot.

Analysis of the molecular mechanism of substrate-mediated inactivation of leukotriene A4 hydrolase

The bifunctional leukotriene A4 hydrolase catalyzes the final step in the biosynthesis of the proinflammatory leukotriene B4. During exposure to the substrate leukotriene A4, a labile allylic epoxide, the enzyme is gradually inactivated as a consequence of the covalent binding of leukotriene A4 to the active site. This phenomenon, commonly referred to as suicide inactivation, has previously been rationalized as a mechanism-based process in which the enzyme converts the substrate to a highly reactive intermediate within an activated enzyme-substrate complex that partitions between covalent bond formation (inactivation) and catalysis. To further explore the molecular mechanism of the self-inactivation of leukotriene A4 hydrolase by leukotriene A4, we prepared and analyzed mutated forms of the enzyme that were either catalytically incompetent or fully active but resistant toward substrate-mediated inactivation. These mutants were treated with leukotriene A4 and leukotriene A4 methyl and ethyl esters and subjected to differential peptide mapping and enzyme activity determinations, which showed that inactivation and/or covalent modification can be completely dissociated from catalysis. Our results, together with recent findings described in the literature, argue against a mechanism-based model for suicide inactivation. We conclude that the collected data on the substrate-mediated inactivation of leukotriene A4 hydrolase best conforms to an affinity-labeling mechanism.

Differences in the gait characteristics of people with diabetes and transmetatarsal amputation compared with age-matched controls

Although qualitative reports in the surgical literature suggest that people with diabetes mellitus (DM) and transmetatarsal amputation (TMA) walk well with regular shoes and a toe-filler, recent data indicates that this population has multiple complications and difficulty with functional mobility. A thorough description of their gait characteristics may provide insights to the cause of these difficulties. The purpose of this study was to compare selected gait characteristics of people with DM and TMA to age-matched controls. We studied 15 subjects with DM and a TMA, and 15 age-matched controls with an overall mean age of 62.3+/-9.2 years. Data were collected with computer assisted video as subjects walked across a force platform. Range-of-motion (ROM), moments, and power were estimated at the ankle, knee, and hip in the sagittal plane using standard link-segment methods. People with DM and TMA had decreased ROM excursion, peak moments, and peak power at the ankle. At the hip, people with DM and a TMA had decreased ROM excursion, an earlier onset of the hip flexor moment, but no differences in peak moments or peak power. Since people with DM and TMA have reduced ability to generate plantar flexor power at the ankle, they appear to rely more heavily on 'pulling' their leg forward from the hip using their hip flexor muscles. This compensation is not complete, however, as people with DM and a TMA take shorter steps and walk slower than controls. Additional research is needed to determine methods to improve or better compensate for these gait deviations during late stance phase. Copyright 1998 Elsevier Science B.V. All rights reserved

Induction of 12-oxo-phytodienoic acid in wounded plants and elicited plant cell cultures

Jasmonic acid (JA) is rapidly biosynthesized from alpha-linolenic acid in plants upon contact with pathogens or wounding, and triggers gene activation, leading to the synthesis of defensive secondary metabolites and proteins. Despite the recent finding that its precursor, 12-oxo-phytodienoic acid (PDA), is a more powerful inducer of gene activation, interest has focused so far almost exclusively on JA. A validated negative chemical ionization-gas chromatography-mass spectrometry method has been developed that allows the simultaneous quantification of endogenous 12-oxo-PDA and JA in plant tissues. In six out of eight plant species tested maximal levels of 12-oxo-PDA exceeded peak levels of JA by approximately 3- to 5-fold after elicitation with a yeast cell wall preparation or when plants were wounded. These experiments support the hypothesis that 12-oxo-PDA acts as the predominant jasmonate signal in most plants, whereas JA remains an active metabolite of its precursor. Furthermore, JA but not 12-oxo-PDA was shown to be secreted into the medium from cultured plant cells, suggesting that JA may also act as an intercellular signal.

Therapeutic footwear: enhanced function in people with diabetes and transmetatarsal amputation

OBJECTIVE

Patients with diabetes mellitus (DM) and a transmetatarsal amputation (TMA) have considerable deficits in function compared with age-matched controls. The purpose of this study was to determine if therapeutic footwear could improve the functional mobility of patients with DM and TMA.

STUDY DESIGN

Repeated-measures design.

SETTING

Academic medical center.

PATIENTS

Thirty subjects (10 women, 20 men) with DM and a TMA, with a mean age of 61.7 +/- 4.0 yrs.

INTERVENTIONS

Six types of footwear evaluating the following components: length of shoe (full-length or short shoe), a rigid rocker-bottom sole, and an ankle-foot-orthosis.

OUTCOME MEASURES

Physical Performance Test (PPT), functional reach, and walking speed. Measurements in each footwear condition occurred after a 1-month adjustment period.

RESULTS

Patients wearing full-length custom-made shoes with a total-contact insert, a rigid rocker-bottom sole or a short shoe with a rigid rocker-bottom sole (with or without an ankle-foot-orthosis) had similar and significantly higher scores in the PPT and faster walking speed than when wearing regular shoes with a toe filler (p < .05). The short shoe and the ankle-foot-orthosis, however, generated many patient complaints about cosmesis and restriction at the ankle, respectively. There were no differences in any of the measures of functional reach.

CONCLUSION

Although there are individual exceptions, we recommend the full-length shoe, total-contact insert, and a rigid rocker-bottom sole for most patients with DM and a TMA.

Functional limitations in patients with diabetes and transmetatarsal amputations

BACKGROUND AND PURPOSE

Reports in the surgical and rehabilitation literature suggest that patients with transmetatarsal amputations (TMAs) function well with regular shoes and a toe filler. Functional limitations, however, have not been documented in this population. The purpose of this study was to compare the function of patients with diabetes mellitus (DM) and TMA with that of age- and gender-matched control subjects.

SUBJECTS

Thirty subjects (15 subjects with DM and TMAs and 15 control subjects), with a mean age of 62.3 years (SD = 9.2, range = 43-83), were studied.

METHODS

Function was measured using the Functional Reach Test (FRT), the Physical Performance Test (PPT), walking speed for 15.2 m (50 ft), and the Sickness Impact Profile (SIP). Subjects in the TMA-DM group wore standard shoes with a toe filler.

RESULTS

The TMA-DM group scored lower (mean +/- standard deviation) than did the control group on all tests (FRT: 19.1 +/- 8.6 vs 31.5 +/- 9.1 cm [7.5 +/- 3.4 vs 12.4 +/- 3.6 in]; PPT: 18.7 +/- 4.8 vs 24.1 +/- 2.2 points [28 points possible]; walking speed: 51.5 +/- 13.2 vs 75.6 +/- 9.3 m/min; SIP: 17.0 +/- 12.7 vs 3.7 +/- 4.7).

CONCLUSION AND DISCUSSION

Persons with DM and TMAs have considerable functional limitations. Research is needed to determine whether therapeutic footwear or other forms of rehabilitation can improve their function.

Therapeutic footwear helps protect the diabetic foot

There is evidence to indicate that therapeutic footwear can help prevent lower extremity amputation in patients with diabetes. The primary means of preventing amputation is to protect the insensitive foot from unnoticed trauma and excessive plantar pressures that occur during walking. The specific prescription of the shoe will depend on many foot risk criteria, but particularly on the patient's level of sensation, history of ulceration, and the amount of foot deformity. This article describes the type of footwear recommended for each of these increasing levels of foot risk categories.

Protein-facilitated export of arachidonic acid from pig neutrophils

Activated neutrophils release a variety of eicosanoids into the extracellular medium including arachidonic acid, 5-hydroxyicosatetraenoic acid, and leukotriene A4 and B4. In this study, the mechanism of arachidonic acid export has been examined using inside-out plasma membrane vesicles from pig polymorphonuclear leukocytes. Tritiated arachidonic acid associated rapidly with the membrane vesicles and crossed the membrane into the intravesicular space in a time-dependent and saturable manner. Half the maximal influx rate was measured at an arachidonate concentration of 5.7 microM, and a maximal influx velocity of 3.0 nmol/mg x min was determined at pH 6.8. Influx into vesicles was sensitive to a number of common anion transport inhibitors including pentachlorophenol, phloretin, diiodosalicylic acid, and quercetin as well as to the proteases trypsin and Pronase, suggesting a protein-dependent process. Furthermore, influx was temperature-sensitive with an energy of activation of 11.6 kcal/mol. Varying extravesicular concentration of ATP, Na+, or K+ had no impact on arachidonate influx, whereas changes in pH had a profound effect; optimum transport activity was observed at an extravesicular pH of 6, whereas raising the pH to 9.5 essentially abolished uptake. These results indicate and initially characterize a novel protein-facilitated arachidonate export mechanism in pig neutrophils.

Effect of six types of footwear on peak plantar pressures in patients with diabetes and transmetatarsal amputation

INTRODUCTION:: Patients with diabetes (DM) and transmetatarsal amputation (TMA) are at high risk for skin breakdown from excessive peak plantar pressures (PPP). The primary purpose of this study was to determine how footwear (full length shoe or short shoe), a total contact insert, a rigid-rocker bottom (RRB) sole, and an ankle-foot-orthosis (AFO) affect PPP on the distal residuum and contralateral extremity of patients with DM and TMA. A secondary purpose was to monitor various functional measures during use of the footwear. METHODS:: Thirty patients with DM and TMA participated (mean age 62+/-4 years). The mean duration of DM was 19.9+/-10.1 years, and the mean time since TMA was 27.4+/-28.1 months. The following footwear was provided after a check-out from an orthotist and physical therapist (PT); 1) Full length shoe (ie shoe length prior to surgery), with a toe filler, 2) full length shoe, total contact insert, and an AFO, 2) full length shoe, total contact insert, and an AFO, 3) full length shoe, total contact insert, and a RRB sole, 4) full length shoe, total contact insert, RRB sole, and an AFO, 5) short shoe (ie length of residuum), total contact insert, and RRB, 6) short shoe, total contact insert, AFO, and RRB sole. In-shoe PPP during walking at the distal residuum and forefoot of the contralateral extremity were measured using the F-Scan System with established reliability under similar conditions (Generilizability coefficient =.75). Each measurement occurred after a one month adjustment period. Data were analyzed using a univariate repeated measuresANOVA. Individual contrasts were used for post-hoc analysis on those variables showing a significant overall F value (p<.05). RESULTS:: Compared to a regular shoe with a toe-filler, all conditions except the short shoe (#5), resulted in lower PPP on the distal residuum (p<.05). Condition 3, the full length shoe, total contact insert, and RRB resulted in lower pressures on the distal residuum and forefoot of the contralateral extremity compared to a regular shoe and toe-filler, and had few functional complaints as identified by the patient, orthotist or PT (3/27). Footwear using an AFO (Conditions 2,4,6) showed reduced PPP on the residuum, but most patients (16/29) had functional complaints. The short shoe (condition 5) had the fewest[Table: see text] functional complaints (2/26), but did not significantly reduce PPP and had the highest cosmetic refusal rate (5/26). DISCUSSION AND CONCLUSIONS:: Although there are individual patient characteristics which warrant other prescriptions, based on the results of this study, we recommend the full length shoe, total contact insert, and RRB sole for most patients with DM and TMA to reduce PPP. A reduction in PPP should help to lower the high risk of skin breakdown in this patient population.

Therapeutic footwear can reduce plantar pressures in patients with diabetes and transmetatarsal amputation

OBJECTIVE

To compare how footwear (full-length shoe or short shoe), a total contact insert, a rigid rocker-bottom (RRB) sole, and an ankle-foot orthosis (AFO) affect peak plantar pressure (PPP) on the distal residuum and contralateral extremity of patients with diabetes and transmetatarsal amputation (TMA).

RESEARCH DESIGN AND METHODS

Thirty patients with diabetes and TMA participated (mean age 62 +/- 4 years). In-shoe plantar pressures during walking were measured in six types of footwear. Each measurement occurred after a 1-month adjustment period. Repeated measure analysis of variance (ANOVA) was used to compare treatments.

RESULTS

All five types of therapeutic footwear reduced plantar pressures compared with regular shoes with a toe-filler (P < 0.05). A full-length shoe, total contact insert, and RRB sole resulted in lower pressures on the distal residuum (222 vs. 284 kPa) and forefoot of the contralateral extremity (197 vs. 239 kPa), compared with a regular shoe and toe-filler. Footwear with an AFO showed reduced PPP on the residuum, but most patients complained of reduced ankle motion during walking. A short shoe reduced pressures on the residuum, but not on the contralateral extremity, and many patients had complaints regarding cosmesis of the shoe.

CONCLUSIONS

The full-length shoe, total contact insert, and an RRB sole provided the best pressure reduction for the residuum and contralateral foot, with the optimal compromise for cosmetic acceptance and function.

Relationships between measures of function, strength and walking speed in patients with diabetes and transmetatarsal amputation

OBJECTIVE

To determine the correlation between strength and functional measures, and the intercorrelation between the functional measures themselves, in a group of subjects with diabetes mellitus (DM) and transmetatarsal amputation (TMA).

DESIGN

Correlational study.

SETTING

The subjects were tested in the Applied Kinesiology Laboratory of the Program in Physical Therapy at Washington University School of Medicine, St Louis, MO, USA.

SUBJECTS

Thirty subjects with DM and TMA (mean age 61.7 +/- 11.3 years) were studied.

MAIN OUTCOME MEASURES

Function was measured using the Functional Reach Test (FR), the Physical Performance Test (PPT), the Sickness Impact Profile (SIP), and walking speed (WS) for 15.24 m. Strength measurements were taken using a hand-held dynamometer.

RESULTS

Highest correlations were found between hip extension strength and PPT: r = 0.69, FR: r = 0.45, and WS: r = 0.76, between knee extension strength and PPT: r = 0.48, and WS: r = 0.51, between hip flexion strength and PPT: r = 0.51, FR: r = 0.47, and WS: r = 0.59, between knee flexion strength and PPT: r = 0.57, and WS: r = 0.63, and between dorsiflexion strength and PPT: r = 0.49, and WS: r = 0.63. The following intercorrelations between functional measures were significant; PPT and FR: r = 0.66, PPT and SIP: r = -0.54, PPT and WS: r = 0.77, FR and WS: r = 0.54, SIP and WS: r = -0.47.

CONCLUSIONS

The relationship between measures of hip and knee muscle strength and function provides some evidence that rehabilitation should focus on strengthening hip and knee extensors and flexors to improve function. The relationships between walking speed and strength, PPT, FR and SIP suggest that the simple measure of walking speed is a useful functional test in the clinic.

Leukotriene A4 hydrolase, mutation of tyrosine 378 allows conversion of leukotriene A4 into an isomer of leukotriene B4

Leukotriene A4 hydrolase catalyzes the final step in the biosynthesis of the proinflammatory compound leukotriene B4, a reaction which is accompanied by suicide inactivation of the enzyme by leukotriene A4. We have recently reported that Tyr-378 is a major structural determinant for suicide inactivation and that mutation of Tyr-378 into Phe or Gln protects leukotriene A4 hydrolase from this catalytic restriction (Mueller, M. J., Blomster, M., Opperman, U. C. T., Jörnvall, H., Samuelsson, B., and Haeggström, J. Z. (1996) Proc. Natl. Acad. Sci. U. S. A. 93, 5931-5935). In the present study, we show that both [Y378F]- and [Y378Q]leukotriene A4 hydrolase converts leukotriene A4 not only into leukotriene B4 but also into a second, previously unknown, product of the enzyme. From biophysical analyses and comparison with a synthetic standard, the structure of this product was determined to 5S,12R-dihydroxy-6,10-trans-8, 14-cis-eicosatetraenoic acid, i.e. Delta6-trans-Delta8-cis-leukotriene B4. The relative formation of Delta6-trans-Delta8-cis-leukotriene B4 versus leukotriene B4 by [Y378F]- and [Y378Q]leukotriene A4 hydrolase, was 18% and 32%, respectively. For [Y378F]leukotriene A4 hydrolase, the turnover of leukotriene A4 into leukotriene B4 or Delta6-trans-Delta8-cis-leukotriene B4 was calculated to 2.5 s-1 which is almost three times the kcat value of the wild type enzyme. Taken together, these findings indicate that Tyr-378 is located at the active site where it assists in the formation of the correct double-bond geometry in the product leukotriene B4.

Leukotriene A4 hydrolase: protection from mechanism-based inactivation by mutation of tyrosine-378

Leukotriene A4 (LTA4) hydrolase [(7E,9E,11Z,14Z)-(5S,6S)-5,6-epoxyicosa-7, 9,11,14-tetraenoate hydrolase; EC 3.3.2.6] is a bifunctional zinc metalloenzyme that catalyzes the final step in the biosynthesis of the potent chemotactic agent leukotriene B4 (LTB4). LTA4 hydrolase/aminopeptidase is suicide inactivated during catalysis via an apparently mechanism-based irreversible binding of LTA4 to the protein in a 1:1 stoichiometry. Previously, we have identified a henicosapeptide, encompassing residues Leu-365 to Lys-385 in human LTA4 hydrolase, which contains a site involved in the covalent binding of LTA4 to the native enzyme. To investigate the role of Tyr-378, a potential candidate for this binding site, we exchanged Tyr for Phe or Gln in two separate mutants. In addition, each of two adjacent and potentially reactive residues, Ser-379 and Ser-380, were exchanged for Ala. The mutated enzymes were expressed as (His)6-tagged fusion proteins in Escherichia coli, purified to apparent homogeneity, and characterized. Enzyme activity determinations and differential peptide mapping, before and after repeated exposure to LTA4, revealed that wild-type enzyme and the mutants [S379A] and [S380A]LTA4hydrolase were equally susceptible to suicide inactivation whereas the mutants in position 378 were no longer inactivated or covalently modified by LTA4. Furthermore, in [Y378F]LTA4 hydrolase, the value of kcat for epoxide hydrolysis was increased 2.5-fold over that of the wild-type enzyme. Thus, by a single-point mutation in LTA4 hydrolase, catalysis and covalent modification/inactivation have been dissociated, yielding an enzyme with increased turnover and resistance to mechanism-based inactivation.

Generalizability of in-shoe peak pressure measures using the F-scan system

In-shoe pressure analysis can be useful in the management of a variety of foot and ankle problems, but guidelines are needed to determine the practical limitations of the measures. The primary purpose of this study was to determine the reliability of peak plantar pressures taken with the F-Scan system over multiple steps, sensors, and days, and using a force platform for additional calibration. Data were collected on 10 healthy subjects as they walked across a force platform for a minimum of three trials on four separate sessions that were 1 week apart. Using a mean of three steps with a single sensor on 1 day, generalizability coefficients were 0.75 for manufacturer calibration and 0.82 with force platform calibration; reliability coefficients for absolute decisions (index of dependability) were 0.60 for manufacturer calibration and 0.76 with force platform calibration. Force measures from the F-Scan and force platform were highly correlated (r = 0.93), but the absolute difference between the measures varied between sensors and over time. RELEVANCE:--Peak pressure measures taken from a mean of three steps with procedures outlined by the F-Scan manufacturer provide pressure values that demonstrate adequate reliability for clinical and research purposes when rank ordering of measures is indicated. If measures are to be used for making absolute decisions (e.g., identifying a threshold for injury), calibration from a stable source such as a force platform is recommended.

Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments

Research indicates that the SW monofilament is an inexpensive, reliable, valid, and easy-to-use clinical indicator for identifying patients who are at risk for developing foot ulcers and subsequent amputations. Those patients unable to sense the 5.07 SW monofilament on any part of their foot should be provided preventive care, including patient education and prescription of appropriate therapeutic footwear.

Leukotriene A4 hydrolase: mapping of a henicosapeptide involved in mechanism-based inactivation

Leukotriene A4 (LTA4) hydrolase [7E,9E,11Z,14Z)-(5S,6S)-5,6-epoxyicosa-7,9 ,11,14-tetraenoate hydrolase; EC 3.3.2.6] is a bifunctional zinc metalloenzyme which converts LTA4 into the chemotactic agent leukotriene B4 (LTB4). Suicide inactivation, a typical feature of LTA4 hydrolase/aminopeptidase, occurs via an irreversible, apparently mechanism-based, covalent binding of LTA4 to the protein in a 1:1 stoichiometry. Differential lysine-specific peptide mapping of unmodified and suicide-inactivated LTA4 hydrolase has been used to identify a henicosapeptide, encompassing the amino acid residues 365-385 of human LTA4 hydrolase, which is involved in the binding of LTA4, LTA4 methyl ester, and LTA4 ethyl ester to the native enzyme. A modified form of this peptide, generated by lysine-specific digestion of LTA4 hydrolase inactivated by LTA4 ethyl ester, could be isolated for complete Edman degradation. The sequence analysis revealed a gap at position 14, which shows that binding of the leukotriene epoxide had occurred via Tyr-378 in LTA4 hydrolase. Inactivation of the epoxide hydrolase and the aminopeptidase activity was accompanied by a proportionate modification of the peptide. Furthermore, both enzyme inactivation and peptide modification could be prevented by preincubation of LTA4 hydrolase with the competitive inhibitor bestatin, which demonstrates that the henicosapeptide contains functional elements of the active site(s). It may now be possible to clarify the molecular mechanisms underlying suicide inactivation and epoxide hydrolysis by site-directed mutagenesis combined with structural analysis of the lipid molecule, covalently bound to the peptide.