Richard A. Alvarez

Comparison of Custom and Prefabricated Orthoses in the Initial Treatment of Proximal Plantar Fasciitis

Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only (P = 0.022) and those who stretched and used a custom orthosis (P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symp-toms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.

Vitamin a transport between retina and pigment epithelium—an interstitial protein carrying endogenous retinol (interstitial retinol-binding protein)

We have demonstrated and partially characterized an interstitial retinol-binding protein (IRBP) confined to bovine interphotoreceptor matrix (IPM). The native protein is a concanavalin A-binding glycoprotein with a mol. wt of 260 k as measured by gel-filtration and size-exclusion high-performance liquid chromatography. On SDS-gels, its mol. wt is 140-145 k. Since the protein is glycosylated, this value is probably too high. Hence, the native protein may be a dimer consisting of two identical subunits. The endogenous ligand has been analyzed by high-performance liquid chromatography--it consists mainly of all-trans retinol. Occasionally, retinal and 11-cis retinol are also associated with it. The amount of retinol bound to IRBP increases when the eyes are illuminated. The total binding capacity was estimated to represent 4-5% of the retinol released from a total rhodopsin bleach. We have established that, like serum retinol-binding protein, IRBP can be also bind retinoic acid, although it has not been established that retinoic acid is an endogenous ligand. The fluorescence emission lambda max for IRBP with its native ligand is at 470 nm and the excitation lambda max for this fluorescence is at 333 nm. Other retinoid carriers in the interphotoreceptor matrix have molecular weights of about 15 and 33 k. These probably correspond to cellular retinol- and retinal-binding proteins, respectively. Since both proteins have been identified in the pigment epithelium and retina cytosols, their presence in the IPM could be a result of cell damage. We conclude that interstitial retinol-binding protein is the best candidate for a transport protein carrying retinol between the rod outer segments and the pigment epithelium.

Rhodopsin, 11-cis vitamin A, and interstitial retinol-binding protein (IRBP) during retinal development in normal and rd mutant mice

Biochemical and immunological techniques were used to determine the emergence of interstitial retinol binding protein (IRBP), rhodopsin, and stored retinyl esters (all-trans and 11-cis) during retinal development in normal and rd mice. IRBP could be demonstrated at embryonic Day 17 (E17), corresponding to an early stage of inner segment development. Although all-trans retinyl esters were present earlier, 11-cis retinyl esters did not appear until postnatal Days 6-7 (P6-P7), corresponding to rod outer segment (ROS) disc formation. Rhodopsin was detected at the same developmental stage. The proportion of 11-cis retinyl esters reached a maximum of 40-50% at P15-P20. Thereafter, the proportion dropped, due to more rapid accumulation of the all-trans isomer. Rhodopsin and IRBP increased in parallel with ROS elongation up to P25, when the ROS had reached their mature lengths. The increases then continued up to P40-P50. In rd (retinal degeneration) mice, IRBP and rhodopsin were identical with the controls until P12, but then dropped as the photoreceptors degenerated. Synthesis and secretion of IRBP in vitro was less than 10% of the controls in rd retinas at P26, when only 4-5% of the photoreceptors survived. The quantities of retinyl esters (mainly stearate and palmitate in the ratio of 6:1, respectively) stored in dark-adapted mouse eyes progressively increased as the animals aged, representing 0.5 mole eq. of the rhodopsin at 8 months. Although retinyl esters (11-cis and all-trans) also accumulated in rd mouse eyes up to P12, little further increase occurred. At P93, the retinyl esters (0.01 nmole X eye-1) were only 4% of the controls at P91. A peak in the proportion of 11-cis isomer occurred at P10-P20, but it averaged only 15% of the total ester and declined to 5% at P93. These findings support the hypothesis that IRBP is synthesized by the rods and cones, and suggest that its synthesis and secretion are initiated when the photoreceptor inner segments start to differentiate. 11-cis Retinoids and rhodopsin do not appear until the outer segments start to form. It is suggested that in the rd mouse the absence of photoreceptors, perhaps coupled with lack of normal interphotoreceptor matrix, leads to a loss in the ability of the pigment epithelium to store retinyl esters.

Visual cycle in the mammalian eye. Retinoid-binding proteins and the distribution of 11-cis retinoids

This work was designed to provide an insight into the mammalian visual cycle by investigating the possible function of retinoid-binding proteins in this system, and the distribution and type of 11-cis retinoids present in the interphotoreceptor matrix and the cytosols of the retinal pigment epithelium and retina. The total retinol and retinal in the soluble fractions from these three compartments was 8% (3.31 nmol/eye) of the retinyl palmitate and stearate stored in the pigment epithelium membrane fractions (39 nmol/eye). Only small amounts of retinoids were detected in the rod outer segment cytosol. The insoluble fractions also contained retinol, nearly all of which was found in the retina. The retinoids in the soluble fractions appeared to be bound to cellular retinol-binding protein (CRBP), cellular retinal-binding protein (CRA1BP) and interstitial retinol-binding protein (IRBP, a high-Mr glycoprotein). Using immunospecific precipitation, immunoblot and immunocytochemical techniques it was demonstrated that IRBP was localized in the interphotoreceptor matrix and was synthesized and secreted by the retina, a process that did not require the protein to be glycosylated. The amount of retinol bound to IRBP increased if the eyes were exposed to light, when it was estimated that the protein carried up to 30% of its full capacity for all-trans retinol. In addition to all-trans retinol, IRBP carried smaller amounts of 11-cis retinol. The proportion of 11-cis retinol was frequently higher in eyes that had been protected from illumination, suggesting that IRBP plays a role in rhodopsin regeneration during dark-adaptation. Additionally, endogenous 11-cis retinoids in the retina and RPE cytosols were bound to an Mr 33,000 protein tentatively identified as CRA1BP. The 11-cis retinoid in the retina cytosol was mainly in the form of retinol, while in the RPE cytosol it was mainly in the form of retinal. Substantial amounts of 11-cis retinol were also found in the insoluble (membrane) fraction from the retina. It is suggested that in the mammalian retina 11-cis retinol is generated from all-trans retinol (possibly in the Muller cells). Lack of an 11-cis retinol oxidoreductase in the retina prevents it from being utilized for rhodopsin regeneration until it has been transported to the pigment epithelium, where it is converted to 11-cis retinal and returned to the rod outer segments. It is also suggested that IRBP may be implicated in the transport of retinoids between the rod outer segments, the Muller cells and the pigment epithelium.(ABSTRACT TRUNCATED AT 400 WORDS)

Metabolism of linolenic acid and docosahexaenoic acid in rat retinas and rod outer segments

Docosahexaenoic acid (22:6 omega 3) is uniquely enriched in photoreceptor outer segment phospholipids, comprising up to one-half of the fatty acids of phosphatidylethanolamine and phosphatidylserine. The current study was designed to investigate the incorporation of 22:6 omega 3 into outer segment phospholipids over 12 days and to determine whether the retina contained the enzymes necessary for elongation and desaturation of the major dietary precursor of 22:6 omega 3, the essential fatty acid linolenic acid (18:3 omega 3). Sprague-Dawley rats were injected intravitreally with [14C]22:6 omega 3 or [14C]18:3 omega 3 and kept in cyclic light (12 hr light/12 hr dark) for 2 hr to 12 days. Phospholipids from rod outer segments and the remaining retinal debris were separated by two-dimensional thin-layer chromatography. [14C]22:6 omega 3 radioactivity was initially highest in phosphatidylcholine and rapidly decreased from 45% of total phospholipid labeling at 2 hr to 26% by 1 and 3 days in ROS, while phosphatidylethanolamine labeling increased from 49 to 68% by 3 days and phosphatidylserine labeling increased from 3 to 14% over 12 days. Phenacyl derivatives of total fatty acids were separated by HPLC. A substantial conversion of [14C]18:3 to [14C]20:5, [14C]22:5 and [14C]22:6 was noted after 1 days, with increasing conversion to [14C]22:6 over the 12-day period. When only one eye was injected with [14C]18:3 omega 3, negligible radioactive fatty acids were detected in the contralateral eye from 1 to 12 days post-injection demonstrating that conversion of 18:3 to 22:6 occurred primarily within the injected eye. All enzymes for elongation and desaturation of 18:3 to 22:6 appear to be present in the eye. However, the conversion of 22:5 to 22:6 by delta-4 desaturase is evidently rate-limiting and may affect phospholipid replacement during photoreceptor outer segment renewal if this pathway proves to be essential for the supply of 22:6 during disk membrane formation.

Separation by programmed-gradient high-pressure liquid chromatography of vitamin A isomers, their esters, aldehydes, oximes and vitamin A2: Presence of retinyl ester in dark-adapted goldfish pigment epithelium

Abstract Mixtures containing isomers of retinol, retinal, retinyl ester, retinal oxime and 3-dehydroretinol were analyzed by programmed-gradient high-pressure liquid chromatography. The method was used to demonstrate the presence of esterified retinol in addition to 3-dehydroretinol in the pigmented ocular layers of dark-adapted goldfish.

Utilization of exogenous retinol by frog pigment epithelium.

High-performance liquid chromatography was used to investigate the utilization of exogenous 11,12-3H2-retinol by frog pigment epithelium (RPE) in vitro or after intraocular injection into the dark-adapted, whole animal. Isolated frog RPE contains an adequate supply of acyl donors and can esterify all-trans, 11-cis and 13-cis isomers of retinol. The esterifying activity is restricted to the particulate fraction. Homogenates of choroid cannot esterify retinol. The ester formed by the RPE is primarily palmitate, and is therefore identical with the endogenous retinyl ester. Frog RPE also formed 13-cis retinyl palmitate from all-trans retinol, probably by esterification of 13-cis retinol formed non-enzymatically from the all-trans isomer. None of the in vitro experiments provided any evidence for the formation of 11-cis retinoid. There was slow appearance of label in 11-cis retinyl palmitate when 3H-all-trans retinol was injected intraocularly into the intact frog. After 15 hr its specific activity was only 20% of that of the all-trans retinyl palmitate. This rate of formation of 11-cis retinoid is inadequate for rhodopsin regeneration. However, it is more than an order of magnitude too fast to be accounted for by phagocytosis of rhodopsin. It is suggested that 11-cis retinoid is generated in the retina and is slowly transferred to the site of esterification in the RPE.

Preliminary results on the safety and efficacy of the OssaTron for treatment of plantar fasciitis.

The OssaTron may be another alternative for management of plantar fasciitis (heel pain syndrome) after failure of non-operative management and prior to surgical management. This study evaluated primarily the safety and early preliminary efficacy of the OssaTron in treatment of patients with plantar fasciitis unresponsive to non-operative management. Twenty heels of 20 patients were treated with 1000 extracorporeal shockwaves from the OssaTron to the affected heel after administration of a heel block. The patients were followed for one year. Each patient was evaluated by roentgenogram, KinCom, range of motion and physical examination, including evaluation of point tenderness by means of a palpometer and according to a 10-cm visual analog scale. The control was the contralateral heel. Patients also performed self evaluation by means of patient activities of daily living questionnaire and pain reported by a 10-cm visual analog scale. There were no complications or adverse effects attributed to the procedure of orthotripsy. Of the 20 patients treated, 18 were improved or pain-free. Eighteen of the 20 subjects treated stated that they would undergo the procedure again instead of surgery. Based on these results, we concluded that orthotripsy is a safe and effective method of treating heel pain syndrome that has been unresponsive to nonoperative management.

Use of high-performance liquid chromatography in the analysis of retinyl and 3,4-didehydroretinyl compounds in tissue extracts of bullfrog tadpoles and goldfish

HPLC (high-performance liquid chromatography) was used to analyse retinyl and 3,4-didehydroretinyl compounds in tissue extracts from goldfish and bullfrog tadpoles. Using silica columns (packed with 10-micron mu Porasil or 5-micron Ultrasphere particles) eluted with n-hexane (containing a small amount of dioxane or diethyl ether), the authentic all-trans retinyl and 3,4-didehydroretinyl palmitates, retinal and 3,4-didehydroretinal, retinol and 3,4-didehydroretinol were completely separated. Liver and eye extracts of the goldfish and bullfrog tadpoles had mainly esterified all-trans retinol and all-trans 3,4-didehydroretinol. In the liver, these vitamin A were conjugated to a number of fatty acids whereas in the eye, principally one fatty acid was used. Moreover, the relative proportions of all-trans retinol and all-trans 3,4-didehydroretinol (obtained by analysing the saponified esters) were significantly different between some of these body compartments.

Bovine interstitial retinol-binding protein (IRBP)—isolation and sequence analysis of cDNA clones, characterization and in vitro translation of mRNA

Three clones for b-IRBP were isolated by anti b-IRBP screening of two bovine retina libraries in the expression vector lambda gt11. The cDNA inserts were then used as hybridization probes to screen and isolate three more clones in a bovine retina library in the non-expression vector lambda gt10. The six overlapping clones generated a b-IRBP cDNA sequence of 3400 nucleotides. An open reading frame encoded the complete amino acid sequences of 8 of the 35 b-IRBP tryptic peptides purified in the present study. One tentative glycosylation site was identified. The coding region was followed by TAG translation terminating codon and an untranslated stretch of about 1700 nucleotides that ended in a sequence containing a presumptive AATAAA polyadenylation signal that was 18 nucleotides upstream from a 10 nucleotide oligo(A) tract. The coding region for b-IRBP would be expected to be 3300 bp long, but Northern blot hybridization experiments performed with bovine retina polyadenylated RNA and probes containing part of the coding region established that the mRNA for b-IRBP consisted of a major species of about 6300 bp, and a minor species of 5200 bp. In vitro translation of bovine retina polyadenylated RNA in a rabbit reticulocyte lysate system yielded an immunoreactive protein that was comparable in size with nonglycosylated, mature IRBP, showing that it is not synthesized from a large precursor, and supporting our finding that the mRNA contains an extensive non-coding region.