Reliability and validity of six-minute step test in patients with heart failure.

Exercise intolerance is the hallmark consequence of advanced chronic heart failure (HF). The six-minute step test (6MST) has been considered an option for the six-minute walk test because it is safe, inexpensive, and can be applied in small places. However, its reliability and concurrent validity has still not been investigated in participants with HF with reduced ejection fraction (HFrEF). Clinically stable HFrEF participants were included. Reliability and error measurement were calculated by comparing the first with the second 6MST result. Forty-eight hours after participants underwent the 6MST, they were invited to perform a cardiopulmonary exercise test (CPET) on a cycle ergometer. Concurrent validity was assessed by correlation between number of steps and peak oxygen uptake (V̇O2 peak) at CPET. Twenty-seven participants with HFrEF (60±8 years old and left ventricle ejection fraction of 41±6%) undertook a mean of 94±30 steps in the 6MST. Intra-rater reliability was excellent for 6MST (ICC=0.9), with mean error of 4.85 steps and superior and inferior limits of agreement of 30.6 and -20.9 steps, respectively. In addition, strong correlations between number of steps and CPET workload (r=0.76, P<0.01) and peak V̇O2 (r=0.71, P<0.01) were observed. From simple linear regression the following predictive equations were obtained with 6MST results: V̇O2 peak (mL/min) = 350.22 + (7.333 × number of steps), with R2=0.51, and peak workload (W) = 4.044 + (0.772 × number of steps), with R2=0.58. The 6MST was a reliable and valid tool to assess functional capacity in HFrEF participants and may moderately predict peak workload and oxygen uptake of a CPET.

Reliability and validity of six-minute step test in patients with heart failure

Exercise intolerance is the hallmark consequence of advanced chronic heart failure (HF). The six-minute step test (6MST) has been considered an option for the six-minute walk test because it is safe, inexpensive, and can be applied in small places. However, its reliability and concurrent validity has still not been investigated in participants with HF with reduced ejection fraction (HFrEF). Clinically stable HFrEF participants were included. Reliability and error measurement were calculated by comparing the first with the second 6MST result. Forty-eight hours after participants underwent the 6MST, they were invited to perform a cardiopulmonary exercise test (CPET) on a cycle ergometer. Concurrent validity was assessed by correlation between number of steps and peak oxygen uptake (V̇O2 peak) at CPET. Twenty-seven participants with HFrEF (60±8 years old and left ventricle ejection fraction of 41±6%) undertook a mean of 94±30 steps in the 6MST. Intra-rater reliability was excellent for 6MST (ICC=0.9), with mean error of 4.85 steps and superior and inferior limits of agreement of 30.6 and -20.9 steps, respectively. In addition, strong correlations between number of steps and CPET workload (r=0.76, P<0.01) and peak V̇O2 (r=0.71, P<0.01) were observed. From simple linear regression the following predictive equations were obtained with 6MST results: V̇O2 peak (mL/min) = 350.22 + (7.333 × number of steps), with R2=0.51, and peak workload (W) = 4.044 + (0.772 × number of steps), with R2=0.58. The 6MST was a reliable and valid tool to assess functional capacity in HFrEF participants and may moderately predict peak workload and oxygen uptake of a CPET.

Validation of the two-minute step test in obese with comorbibities and morbidly obese patients.

Cardiopulmonary fitness assessment is a valuable resource to obtain quantitative indicators of an individual's physical performance. The cardiopulmonary exercise test (CPX), considered the gold standard test for this evaluation, is costly and difficult to be accessed by the general population. In order to make this evaluation more accessible, and to better reflect the performance of daily life activities, alternative tests were proposed. Morbidly obese patients present limitations that impair physical performance assessment and could benefit from a test of shorter duration, provided it is validated. This observational study aimed to validate the two-minute step test (2MST) as a tool to evaluate functional capacity (FC) in obese with comorbidities and morbidly obese patients, compared the 2MST with CPX as a measure of physical performance, and developed a predictive equation to estimate peak oxygen uptake (VO2) in the 2MST. The CPX and the 2MST were performed and metabolic and ventilatory parameters were recorded in 31 obese individuals (BMI>35 kg/m2). Pearson correlation and multiple linear regression analyses were performed to evaluate the peak VO2 best predictors. Bland-Altman analysis was performed to assess the agreement between the two methods. Peak VO2 measured by CPX and 2MST showed a strong correlation (r=0.70, P<0.001) and there was a moderate correlation between peak VO2 of the 2MST and the number of up-and-down step cycles (UDS) (r=0.55; P=0.01). The reference equation obtained was: VO2 (mL·kg-1·min-1) = 13.341 + 0.138 × total UDS - (0.183 × BMI), with an estimated standard error of 1.3 mL·kg-1·min-1. The 2MST is a viable, practical, and easily accessible test for FC. UDS and BMI can predict peak VO2 satisfactorily.

Validation of the two-minute step test in obese with comorbibities and morbidly obese patients

Cardiopulmonary fitness assessment is a valuable resource to obtain quantitative indicators of an individual's physical performance. The cardiopulmonary exercise test (CPX), considered the gold standard test for this evaluation, is costly and difficult to be accessed by the general population. In order to make this evaluation more accessible, and to better reflect the performance of daily life activities, alternative tests were proposed. Morbidly obese patients present limitations that impair physical performance assessment and could benefit from a test of shorter duration, provided it is validated. This observational study aimed to validate the two-minute step test (2MST) as a tool to evaluate functional capacity (FC) in obese with comorbidities and morbidly obese patients, compared the 2MST with CPX as a measure of physical performance, and developed a predictive equation to estimate peak oxygen uptake (VO2) in the 2MST. The CPX and the 2MST were performed and metabolic and ventilatory parameters were recorded in 31 obese individuals (BMI>35 kg/m2). Pearson correlation and multiple linear regression analyses were performed to evaluate the peak VO2 best predictors. Bland-Altman analysis was performed to assess the agreement between the two methods. Peak VO2 measured by CPX and 2MST showed a strong correlation (r=0.70, P<0.001) and there was a moderate correlation between peak VO2 of the 2MST and the number of up-and-down step cycles (UDS) (r=0.55; P=0.01). The reference equation obtained was: VO2 (mL·kg-1·min-1) = 13.341 + 0.138 × total UDS - (0.183 × BMI), with an estimated standard error of 1.3 mL·kg-1·min-1. The 2MST is a viable, practical, and easily accessible test for FC. UDS and BMI can predict peak VO2 satisfactorily.

Relationship between aerobic capacity and pelvic floor muscles function: a cross-sectional study.

The objective of this study was to evaluate the relationship between aerobic capacity and pelvic floor muscles (PFM) function in adult women. Women aged 18 or over and without urinary dysfunction or other chronic diseases were eligible to participate. They completed the habitual physical activity (HPA) questionnaire, underwent a PFM functional evaluation by palpation and perineometry, and performed a submaximal (between 75 and 85% of maximum heart rate) cardiopulmonary exercise (CPX) test to determine the ventilatory anaerobic threshold (VAT). Forty-one women were included (35±16 years, 75% physically active, 17% very active, and 8% sedentary and 17% presented grade 1 PFM contraction, 31.8% grade 2, 26.8% grade 3, and 24.4% grade 4, according to the modified Oxford Scale). The average PFM contraction pressure obtained by perineometer was 53±26 cmH2O and the average oxygen consumption at VAT (VO2VAT) obtained from CPX was 14±2 mL·kg-1·min-1. Significant correlations were found between PFM contraction pressure and VO2VAT (r=0.55; P<0.001); between PFM contraction pressure and HPA score (r=0.38; P=0.02); between age and VO2VAT (r=-0.25; P=0.049); and between VO2VAT and HPA score (r=0.36; P=0.02). An age-adjusted multiple linear regression equation (R2=0.32) was derived to estimate VO2VAT from the contraction value obtained by perineometer, so that the PFM contraction pressure was able to predict VO2VAT. The equation was validated using data from another group of 20 healthy women (33±12 years; PFM contraction: 49±23 cmH2O) and no significant difference was found between actual VO2VAT and predicted VO2VAT (13.1±1.9 vs 13.8±2.0 mL·kg-1·min-1). In conclusion, PFM function is associated with aerobic capacity in healthy women and PFM contraction pressure may be used to estimate VO2VAT in this population.

[Desmopressin in the Treatment of Enuresis: Is Lyophilisate Superior to Tablets?] / Desmopressin in der Behandlung der Enuresis: Ist das Lyophilisat den Tabletten überlegen?

Background: Prognosis of MNE is good when adequate treatment starts in a timely manner. First-line treatment for monosymptomatic nocturnal enuresis (MNE) includes desmopressin (Grade A/Level 1 recommendation from the ICI). Missing or insufficient response to pharmacological treatment can be caused by incomplete compliance, but might also be associated with differences in bioavailability from the tablet form. This prospective, non-interventional study was designed to compare desmopressin tablets to the newer ,,melt'' formulation, also known as lyophilisate or orally disintegrating tablet (ODT). The primary endpoint of this study was the patients'/parents' acceptance; the secondary end point was a decrease in the number of wet nights. Materials and Methods: Each of the scheduled 100 participating doctors had to recruit two MNE candidates, one for each treatment group, with a planned total of 200 participants. At the end of the treatment period, treatment satisfaction, difficulties in taking the medication, forgotten doses and treatment success were reported. Results: In total, 134 patients were included (49 on tablet and 84 on melt). Difficulties in taking the medication and forgotten doses were significantly less with the melt than with the tablet formulation. Treatment satisfaction was better with melt. After the 3 months study, the number of wet nights was considerably reduced in both groups. With lyophilisate, a statistically significant greater reduction in wet nights was recorded as early as 2 weeks after starting the treatment. Conclusion: Desmopressin as orally disintegrating tablets is an effective treatment and is associated with improved patient compliance.

Does the incremental shuttle walk test require maximal effort in young obese women?

Obesity is a chronic disease with a multifaceted treatment approach that includes nutritional counseling, structured exercise training, and increased daily physical activity. Increased body mass elicits higher cardiovascular, ventilatory and metabolic demands to varying degrees during exercise. With functional capacity assessment, this variability can be evaluated so individualized guidance for exercise training and daily physical activity can be provided. The aim of the present study was to compare cardiovascular, ventilatory and metabolic responses obtained during a symptom-limited cardiopulmonary exercise test (CPX) on a treadmill to responses obtained by the incremental shuttle walk test (ISWT) in obese women and to propose a peak oxygen consumption (VO2) prediction equation through variables obtained during the ISWT. Forty obese women (BMI ≥30 kg/m2) performed one treadmill CPX and two ISWTs. Heart rate (HR), arterial blood pressure (ABP) and perceived exertion by the Borg scale were measured at rest, during each stage of the exercise protocol, and throughout the recovery period. The predicted maximal heart rate (HRmax) was calculated (210 - age in years) (16) and compared to the HR response during the CPX. Peak VO2 obtained during CPX correlated significantly (P<0.05) with ISWT peak VO2 (r=0.79) as well as ISWT distance (r=0.65). The predictive model for CPX peak VO2, using age and ISWT distance explained 67% of the variability. The current study indicates the ISWT may be used to predict aerobic capacity in obese women when CPX is not a viable option.

Does the incremental shuttle walk test require maximal effort in young obese women?

Obesity is a chronic disease with a multifaceted treatment approach that includes nutritional counseling, structured exercise training, and increased daily physical activity. Increased body mass elicits higher cardiovascular, ventilatory and metabolic demands to varying degrees during exercise. With functional capacity assessment, this variability can be evaluated so individualized guidance for exercise training and daily physical activity can be provided. The aim of the present study was to compare cardiovascular, ventilatory and metabolic responses obtained during a symptom-limited cardiopulmonary exercise test (CPX) on a treadmill to responses obtained by the incremental shuttle walk test (ISWT) in obese women and to propose a peak oxygen consumption (VO2) prediction equation through variables obtained during the ISWT. Forty obese women (BMI ≥30 kg/m2) performed one treadmill CPX and two ISWTs. Heart rate (HR), arterial blood pressure (ABP) and perceived exertion by the Borg scale were measured at rest, during each stage of the exercise protocol, and throughout the recovery period. The predicted maximal heart rate (HRmax) was calculated (210 – age in years) (16) and compared to the HR response during the CPX. Peak VO2 obtained during CPX correlated significantly (P<0.05) with ISWT peak VO2 (r=0.79) as well as ISWT distance (r=0.65). The predictive model for CPX peak VO2, using age and ISWT distance explained 67% of the variability. The current study indicates the ISWT may be used to predict aerobic capacity in obese women when CPX is not a viable option.

Effects of acute relapses on neuropsychological status in multiple sclerosis patients.

Little is known about neuropsychological status changes in multiple sclerosis (MS) patients experiencing a relapse. The Symbol Digit Modalities Test (SDMT) and MS Neuropsychological Screening Questionnaire (MSNQ) are brief measures of cognitive performance and self-reported status, respectively. We retrospectively identified relapses in subjects participating in the 48-week open-label, safety-extension study of natalizumab (STRATA) to determine if changes in cognitive ability occurred during acute relapses. SDMT and MSNQ were administered prior to infusions. We analyzed SDMT and MSNQ scores pre- and post-relapse in 53 MS patients with relapses (cases) and 115 MS patients without relapses (controls) matched on age, gender, baseline SDMT and time from study initiation. ANOVA and GLM were used to compare cases versus controls overall, and stratified by EDSS cerebral functional status (cFS) scores. SDMT change pre- to post-relapse in cases was significantly lower than difference between similar time points in controls (p = 0.003). When comparing visit 2 (two visits pre-relapse) to visit 1 (first visit post-relapse), MSNQ change was significantly different between cases and controls (p = 0.012). For cFS ≤ 1, the change in SDMT was significantly different between cases and controls but not for cFS ≥ 2. These results confirm the involvement of cognitive function during some MS relapses suggesting the SDMT or MSNQ can be used to identify transitory neuropsychological status changes and cognitive relapses.

Evaluation of the symbol digit modalities test (SDMT) and MS neuropsychological screening questionnaire (MSNQ) in natalizumab-treated MS patients over 48 weeks.

BACKGROUND AND OBJECTIVES: Brief cognitive tests to monitor cognitive impairment in patients with multiple sclerosis (MS) are needed. METHODS: Performance on monthly administrations of the Symbol Digit Modalities Test (SDMT) and the MS Neuropsychological Questionnaire (MSNQ) was assessed in 660 patients with MS in 21 countries (109 sites) for 48 weeks in an open-label, safety-extension study of natalizumab. RESULTS: At baseline, the cohort's mean age was 40.1 years, 67.6% were female and the median Expanded Disability Status Scale score was 2.5. Test-retest correlations were high for both SDMT (range 0.89 for weeks 0-4 to 0.96 for weeks 44-48) and MSNQ (0.82 for weeks 0-4 to 0.93 for weeks 44-48). There were no statistically significant effects of geographic region. While SDMT scores improved by 15 points over 48 weeks (p < 0.0001), incremental monthly changes were small (effect size d < 0.3). Similar results were obtained on the MSNQ except that scores moved downward, suggesting fewer cognitive complaints over 48 weeks (p < 0.0001), but again the incremental monthly changes were small (d <-0.2). CONCLUSIONS: These results replicate earlier work in a smaller cohort treated with conventional disease-modifying therapy, and support the reliability of the SDMT and MSNQ as potential screening for monitoring tools for cognition over time.

[Living donation liver transplantation in children]. / Lebendspende-Lebertransplantation beim Kind.

Liver transplantation is the first-line therapy for children with acute and chronic hepatic failure, metabolic liver diseases and liver tumors. As most of the children with end-stage liver disease are very small in stature the resources of compatible organs of deceased donors are limited. Living liver donation was able to nearly eliminate waiting list mortality with excellent patient and graft survival. As 80% of the pediatric recipients have a body weight <25 kg donation of the left lateral lobe (segments II+III) is sufficient in most of the cases. According to a standardization of the surgical procedures as well as the preoperative, intraoperative and postoperative management donation of the left lateral lobe advanced to a procedure with very low donor morbidity and mortality rates. The complexity of hepatic disease patterns in pediatric patients which often affect other organ systems demand a close cooperation with an experienced pediatric team. Pediatric living donor liver transplantation requires high expertise in liver surgery and split liver transplantation and should therefore only be performed in transplant centers meeting these high qualifications.

Effect of plasma exchange in accelerating natalizumab clearance and restoring leukocyte function.

BACKGROUND: Accelerating the clearance of therapeutic monoclonal antibodies (mAbs) from the body may be useful to address uncommon but serious complications from treatment, such as progressive multifocal leukoencephalopathy (PML). Treatment of PML requires immune reconstitution. Plasma exchange (PLEX) may accelerate mAb clearance, restoring the function of inhibited proteins and increasing the number or function of leukocytes entering the CNS. We evaluated the efficacy of PLEX in accelerating natalizumab (a therapy for multiple sclerosis [MS] and Crohn disease) clearance and alpha4-integrin desaturation. Restoration of leukocyte transmigratory capacity was evaluated using an in vitro blood-brain barrier (ivBBB). METHODS: Twelve patients with MS receiving natalizumab underwent three 1.5-volume PLEX sessions over 5 or 8 days. Natalizumab concentrations and alpha4-integrin saturation were assessed daily throughout PLEX and three times over the subsequent 2 weeks, comparing results with the same patients the previous month. Peripheral blood mononuclear cell (PBMC) migration (induced by the chemokine CCL2) across an ivBBB was assessed in a subset of six patients with and without PLEX. RESULTS: Serum natalizumab concentrations were reduced by a mean of 92% from baseline to 1 week after three PLEX sessions (p < 0.001). Although average alpha4-integrin saturation was not reduced after PLEX, it was reduced to less than 50% when natalizumab concentrations were below 1 mug/mL. PBMC transmigratory capacity increased 2.2-fold after PLEX (p < 0.006). CONCLUSIONS: Plasma exchange (PLEX) accelerated clearance of natalizumab, and at natalizumab concentrations below 1 mug/mL, desaturation of alpha4-integrin was observed. Also, CCL2-induced leukocyte transmigration across an in vitro blood-brain barrier was increased after PLEX. Therefore, PLEX may be effective in restoring immune effector function in natalizumab-treated patients.

Repeated assessment of neuropsychological deficits in multiple sclerosis using the Symbol Digit Modalities Test and the MS Neuropsychological Screening Questionnaire.

BACKGROUND: Brief cognitive performance tests and self-report measures of neuropsychological symptoms have been proposed for screening purposes in multiple sclerosis (MS) clinics. To better understand the reliability of screening methods, two tests, the Symbol Digit Modalities Test (SDMT) and the MS Neuropsychological Screening Questionnaire (MSNQ), were administered to 76 patients with MS and 25 healthy controls, matched on demographic characteristics. METHODS: Tests were administered at monthly intervals, over 6 months. In addition, the Beck Depression Inventory Fast Screen for medical patients (BDIFS) was administered to monitor for changes in depression. Our objectives were to determine the reliability of these measures and the relative contribution of cognitive impairment and depression in predicting self-report MSNQ scores. RESULTS: Results showed that both the SDMT and MSNQ have good to excellent reproducibility over repeated testing. In MS, there are minimal practice effects over successive tests, in the order of 0.2 SD for SDMT and minimal change in the MSNQ. Regression analyses modeled to predict MSNQ based on SDMT and BDIFS showed significant contribution for both, but with the majority of variance being accounted for depression. CONCLUSIONS: We conclude that these brief screening tests provide some independent information about the mental status of patients with MS and are reliable, even when used in monthly, successive examinations.

Construction of D29 shuttle phasmids and luciferase reporter phages for detection of mycobacteria.

Diseases caused by Mycobacterium tuberculosis, M. leprae and M. avium, cause significant morbidity and mortality worldwide. Effective treatments require that the organisms be speciated and that drug susceptibilities for the causative organisms be characterized. Reporter phage technology has been developed as a rapid and convenient method for identifying mycobacterial species and evaluating drug resistance. In this report we describe the construction of luciferase reporter phages from mycobacteriophage D29 DNA. Shuttle phasmids were first constructed with D29 in order to identify non-essential regions of the D29 genomes and to introduce unique cloning sites within that region. Using this approach, we observed that all of the D29 shuttle phasmids had the cosmid vector localized to one area of the phage genome near one cohesive end. These shuttle phasmids had been constructed with a cosmid that could be readily excised from the D29 genome with different sets of restriction enzymes. Luciferase reporter phages were made by substituting the luciferase cassette for the cosmid vector. Recombinant phages with the luciferase cassette fall into two groups. One group produced light and had the expression cassette oriented with the promoter directing transcription away from the cohesive end. In contrast, the other group had the expression cassette in the opposite orientation and failed to produce light during lytic infection, but did produce light in L5 lysogens which are known to repress D29 promoters. These results suggest that a phage promoter of the D29 phage can occlude the expression of a promoter introduced into this region. D29 luciferase reporter phages are capable of detecting low numbers of L5 lysogens like L5 luciferase phages. However, unlike L5 luciferase phages, D29 luciferase phages can readily infect M. tuberculosis and M. bovis BCG, demonstrating that these phages can be used to evaluate drug susceptibilities of many types of mycobacteria.

Chemiluminescent detection of strand displacement amplified DNA from species comprising the Mycobacterium tuberculosis complex.

Strand displacement amplification, a new isothermal in vitro DNA amplification technique, was used to amplify target DNA contained within the IS6110 insertion element of the species within the Mycobacterium complex (Mycobacterium tuberculosis, M. bovis, M. bovis-BCG, M. africanum and M. microti). The target nucleic acid sequence is present in approximately ten, two, one, five and five copies in M. tuberculosis, M. bovis, M. bovis-BCG, M. africanum and M. microti, respectively. Amplified products were detected using a non-isotopic microtitre plate assay employing a biotinylated oligodeoxynucleotide probe and an alkaline phosphatase conjugated oligodeoxynucleotide probe. Lumiphos 530 was the chemiluminescent substrate for alkaline phosphatase. The combination of the strand displacement amplification method with this sensitive and rapid (less than 2 h) detection system resulted in the specific detection of as few as 1-25 initial IS6110 targets in the five Mycobacterium complex species based on signal/noise criteria. Negative results were obtained with eight other Mycobacterium species as well as with 32 non-Mycobacterium species.

Inhibition of the Mg(II).ATP-dependent phosphoprotein phosphatase by the regulatory subunit of cAMP-dependent protein kinase.

We report potent inhibition of the Mg(II).ATP-dependent protein phosphatase, Fc.M, by the regulatory subunit dimer of type II cAMP-dependent protein kinase, RII2. The protein kinase catalytic subunit has no effect on phosphatase activity and is unable to substitute for kinase FA in the kinase FA- and Mg(II).ATP-mediated phosphatase activation reaction. Phosphatase inhibition was investigated as a function of RII2 concentration. The results suggest that RII2 both inhibits the active phosphatase and inhibits phosphatase activation. The inhibition is shown to be noncompetitive with respect to substrate (phosphorylase a). The potential physiological significance of this inhibition is discussed in terms of phosphorylation/dephosphorylation cascade systems involving this kinase and phosphatase.

Kinase FA-mediated regulation of rabbit skeletal muscle protein phosphatase. Reversible phosphorylation of the modulator subunit.

A mechanism of activation of the ATP.Mg-dependent protein phosphatase (FC.M) has been proposed (Jurgensen, S., Shacter, E., Huang, C. Y., Chock, P. B., Yang, S.-D., Vandenheede, J. R., and Merlevede, W. (1984) J. Biol. Chem. 259, 5864-5870) in which a transient phosphorylation by the kinase FA of the modulator subunit (M) is the driving force for the transition of the inactive catalytic subunit (FC) into its active conformation. Incubation of FC.M with kinase FA and Mg2+ and adenosine 5'-(gamma-thio)triphosphate results in thiophosphorylation of M and also a conformational change in the phosphatase catalytic subunit; however, the enzyme remains inactive. Proteolysis of this inactive, thiophosphorylated complex causes proteolytic destruction of the modulator subunit and yields an active phosphorylase phosphatase species. Similar treatment of the native inactive enzyme does not yield active phosphatase. Evidence is presented, suggesting that a molecule of modulator is bound at an "inhibitory site" on the native enzyme. This modulator does not prevent the conformational change in the phosphatase catalytic subunit upon incubation with kinase FA and ATP.Mg but does partially inhibit the expression of the phosphorylase phosphatase activity.

On the mechanism of activation of the ATP X Mg(II)-dependent phosphoprotein phosphatase by kinase FA.

The mechanism of activation of the Mg(II) X ATP-dependent phosphatase by the kinase FA has been investigated. The inactive protein phosphatase can be represented as FC X M where FC is the inactive catalytic component and M is the heat-stable modulator protein (also known as inhibitor-2). Phosphorylation of the modulator protein is demonstrated during activation of FC X M. In addition, continuous ATP hydrolysis during the activation is observed. This suggests that a cyclic phosphorylation-dephosphorylation reaction is continuously occurring during the activation. It is proposed that phosphorylation of the modulator protein causes an isomerization in FC to generate an active phosphatase. The activated phosphatase is capable of dephosphorylating the phosphorylated modulator. Upon dephosphorylation of modulator, the active phosphatase returns to its inactive form via a slow isomerization.