Reliability and validity of the sideways step test and its correlation with motor function after stroke

[Purpose] This study investigated the intra-rater, inter-rater and test-retest reliability of the sideways step test (SST), its correlation with other indicators of stroke-specific impairment, and the cut-off count best discriminating subjects with stroke from their healthy counterparts. [Subjects and Methods] Forty-three subjects with chronic stroke and 41 healthy subjects older than 50 years participated in this study. The SST was administered along with the Fugl-Meyer motor assessment for the lower extremities (FMA-LE), the five-times sit to stand (5TSTS) test, the Berg Balance Scale (BBS), the movement velocity (MVL) by the limits of stability (LOS) test, the ten-metre walk (10mW) test, the timed “Up and Go” (TUG) test and the Activities-specific Balance Confidence (ABC) scale. [Results] The SST showed good to excellent intra-rater, inter-rater and test-retest reliability. The SST counts correlated with 5TSTS times, 10mW times, TUG times, and the FMA-LE and BBS scores. SST counts of 11 for the paretic leg and 14 for the non-paretic leg were found to distinguish the healthy adults from subjects with stroke. [Conclusion] The sideways step test is a reliable clinical test, which correlates with the functional strength, gait speed, and functional balance of people with chronic stroke.Key words: Balance, Stroke, Rehabilitation     

Ischemic preconditioning-mediated cardioprotection is disrupted in heterozygous Flt-1 (VEGFR-1) knockout mice

This study attempts to address an important clinical issue by identifying potential candidates of VEGF signaling through Flt-1 receptor that trigger angiogenic signal under ischemic stress. To determine the significance of VEGF-Flt-1 (VEGFR1) signaling in ischemic preconditioned (PC) myocardium, we used heterozygous Flt-1 knockout (KO) mice to dissect the pathway and identify candidate genes involved in VEGF signaling. DNA microarrays were employed to detect, characterize and distinguish altered myocardial gene expression by comparing between wild type (WT) CD-1 and heterozygous Flt-1 KO mice when exposed to ischemia (30 min) and reperfusion (2 h). Moreover, KO mice demonstrated reduced beneficial effects of PC when compared to the WT with PC. In the KO and WT mice, the % recovery of the left ventricular developed pressure and the maximum first derivative of the developed pressure after ischemia/reperfusion without PC were similar. However, when animals were subjected to PC, the left ventricular functional recovery throughout the reperfusion period was significantly lower in KO mice than in WT mice. These results indicate for the first time that in the heterozygous Flt-1 KO mice, PC is not as effective as that found in WT. This observation may be due to downregulation of several important genes such as growth-regulated oncogene 1 (Gro1), heat shock proteins (HSP), I kappa B kinase beta (IKK beta), colony-stimulating factor-1 (CSF-1) and annexin A7, suggesting the importance of VEGF-Flt-1 receptor signaling during PC.     

Activated protein C resistance: molecular mechanisms based on studies using purified Gln506-factor V

Gln506-factor V (FV) was purified from plasma of an individual homozygous for an Arg506Gln mutation in FV that is associated with activated protein C (APC) resistance. Purified Gln506-FV, as well as Gln506-FVa generated by either thrombin or FXa, conveyed APC resistance to FV-deficient plasma in coagulation assays. Clotting assay studies also suggested that APC resistance does not involve any abnormality in FV-APC-cofactor activity. In purified reaction mixtures, Gln506-FVa in comparison to normal FVa showed reduced susceptibility to APC, because it was inactivated approximately 10-fold slower than normal Arg506-FVa. It was previously reported that inactivation of normal FVa by APC involves an initial cleavage at Arg506 followed by phospholipid- dependent cleavage at Arg306. Immunoblot and amino acid sequence analyses showed that the 102-kD heavy chain of Gln506-FVa was cleaved at Arg306 during inactivation by APC in a phospholipid-dependent reaction. This reduced but measurable susceptibility of Gln506-FVa to APC inactivation may help explain why APC resistance is a mild risk factor for thrombosis because APC can inactivate both normal FVa and variant Gln506-FVa. In summary, this study shows that purified Gln506- FV can account for APC resistance of plasma because Gln506-FVa, whether generated by thrombin or FXa, is relatively resistant to APC.     

Hematological,Hepatic, and Retinal Phenotypes in Mice Deficient for Prolyl Hydroxylase Domain Proteins in the Liver

Prolyl hydroxylase domain (PHD) proteins catalyze oxygen-dependent prolyl hydroxylation of hypoxia-inducible factor 1α and 2α, tagging them for pVHL-dependent polyubiquitination and proteasomal degradation. In this study, albumin Cre (Alb^Cre)–mediated, hepatocyte-specific triple disruption of Phd1, Phd2, and Phd3 (Phd(1/2/3)hKO) promoted liver erythropoietin (EPO) expression 1246-fold, whereas renal EPO was down-regulated to 6.7% of normal levels. In Phd(1/2/3)hKO mice, hematocrit levels reached 82.4%, accompanied by severe vascular malformation and steatosis in the liver. In mice double-deficient for hepatic PHD2 and PHD3 (Phd(2/3)hKO), liver EPO increase and renal EPO loss both occurred but were much less dramatic than in Phd(1/2/3)hKO mice. Hematocrit levels, vascular organization, and liver lipid contents all appeared normal in Phd(2/3)hKO mice. In a chronic renal failure model, Phd(2/3)hKO mice maintained normal hematocrit levels throughout the 8-week time course, whereas floxed controls developed severe anemia. Maintenance of normal hematocrit levels in Phd(2/3)hKO mice was accomplished by sensitized induction of liver EPO expression. Consistent with such a mechanism, liver HIF-2α accumulated to higher levels in Phd(2/3)hKO mice in response to conditions causing modest systemic hypoxia. Besides promoting erythropoiesis, EPO is also known to modulate retinal vascular integrity and neovascularization. In Phd(1/2/3)hKO mice, however, neonatal retinas remained sensitive to oxygen-induced retinopathy, suggesting that local EPO may be more important than hepatic and/or renal EPO in mediating protective effects in the retina.Prolyl hydroxylase domain (PHD) proteins PHD1, PHD2, and PHD3 use molecular oxygen as a substrate to hydroxylate specific prolyl residues in HIF-1α and HIF-2α,^1–3 tagging them for von Hippel–Lindau protein (pVHL)–dependent polyubiquitination and proteasomal degradation.⁴ PHD-regulated HIF-α stability is important for multiple processes, including angiogenesis,^5–7 erythropoiesis,^8–10 cardiomyocyte function,^11–13 cell survival,¹⁴ and metabolism.¹⁵ PHD1 and PHD2 also hydroxylate IKKβ, thus regulating the assembly of NF-κB and functions of monocytic cells and proangiogenic macrophages.^16–19 Besides PHDs, a transmembrane prolyl hydroxylase in the endoplasmic reticulum (P4H-TM) may also regulate HIF-α stability.^20,21In normal adults, renal interstitial cells are responsible for the bulk of plasma erythropoietin (EPO) and thus play a key role in regulating erythropoiesis and blood homeostasis. Loss or dysfunction of renal interstitial cells due to acute renal injury or chronic kidney disease can lead to EPO deficiency and severe anemia.²² Normal liver expresses EPO only at very low levels, but possesses latent capacity for EPO expression that can be reactivated by manipulations that lead to hepatic HIF-2α stabilization. For example, hepatocyte-specific Vhl knockout in mice resulted in the accumulation of HIF-1α and HIF-2α to high levels, and subsequent studies showed that HIF-2α was responsible for elevated liver EPO expression and polycythemia.^23,24 Other studies have also demonstrated critical roles of HIF-2α in regulating EPO expression.^25,26Our research group has previously shown that germline Phd1 and Phd3 double knockout leads to increased liver EPO expression.⁸ In a more recent study, Minamishima and Kaelin²⁷ showed that more dramatic liver EPO up-regulation can be induced by triple Phd knockout, with Phd1 and Phd3 knockout being germline null mutations and Phd2 knockout induced in a hepatocyte-restricted manner. These studies raised the possibility that the liver may be exploited as an alternative source for endogenous EPO production in case of renal failure. Indeed, siRNA-mediated knockdown of hepatic PHD rescued erythropoiesis in mice subjected to 5/6 nephrectomy.²⁸ Although these findings are highly encouraging, it is not known how the liver itself is affected by PHD deficiency.In the present study, we examined hematological effects of hepatic PHD deficiency in an established chronic renal failure model,^29–32 and compared blood, vascular, and lipid phenotypes associated with the disruption of different combinations of PHD isoforms in the liver. Hepatic triple deficiency of all three isoforms caused multiple abnormalities, including severe erythrocytosis, vascular malformation, and massive lipid accumulation in the liver. By contrast, mice double-deficient for hepatic PHD2 and PHD3 did not exhibit any of these defects, but yet gained the ability to maintain normal hematocrit (Hct) levels in a chronic renal failure model. These data provide the proof of principle that selective combinations of hepatic PHD isoforms could offer suitable therapeutic targets for maintaining normal blood homeostasis without accompanying vascular malformation or liver steatosis.