[Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER Statement]

Measurements of health indicators are rarely available for every population and period of interest, and available data may not be comparable. The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) define best reporting practices for studies that calculate health estimates for multiple populations (in time or space) using multiple information sources. Health estimates that fall within the scope of GATHER include all quantitative population-level estimates (including global, regional, national, or subnational estimates) of health indicators, including indicators of health status, incidence and prevalence of diseases, injuries, and disability and functioning; and indicators of health determinants, including health behaviours and health exposures. GATHER comprises a checklist of 18 items that are essential for best reporting practice. A more detailed explanation and elaboration document, describing the interpretation and rationale of each reporting item along with examples of good reporting, is available on the GATHER website (http://gather-statement.org).

Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement

Measurements of health indicators are rarely available for every population and period of interest, and available data may not be comparable. The Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) define best reporting practices for studies that calculate health estimates for multiple populations (in time or space) using multiple information sources. Health estimates that fall within the scope of GATHER include all quantitative population-level estimates (including global, regional, national, or subnational estimates) of health indicators, including indicators of health status, incidence and prevalence of diseases, injuries, and disability and functioning; and indicators of health determinants, including health behaviours and health exposures. GATHER comprises a checklist of 18 items that are essential for best reporting practice. A more detailed explanation and elaboration document, describing the interpretation and rationale of each reporting item along with examples of good reporting, is available on the GATHER website.

Correction: Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement

[This corrects the article DOI: 10.1371/journal.pmed.1002056.].

Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement

Gretchen Stevens and colleagues present the GATHER statement, which seeks to promote good practice in the reporting of global health estimates.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study

Objective

To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities.

Methods

We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level.

Findings

A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities.

Conclusion

The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Somatostatin analogues improve health-related quality of life in polycystic liver disease: a pooled analysis of two randomised, placebo-controlled trials

BACKGROUND

Polycystic liver disease is associated with impaired health-related quality of life (HRQL). Somatostatin analogues reduce hepatomegaly in polycystic liver disease.

AIM

To determine whether somatostatin analogues improve HRQL and to identify factors associated with change in HRQL in polycystic liver disease.

METHODS

We pooled data from two randomized, double-blind, placebo-controlled trials that evaluated HRQL using the Short-Form 36 (SF-36) in 96 polycystic liver disease patients treated 6-12 months with somatostatin analogues or placebo. The SF-36 contains a summarizing physical and mental component score and was administered at baseline and at the end of treatment. We used random effect models to delineate the effect of somatostatin analogues on HRQL. We determined the effect of demographics, height-adjusted liver volume, change in liver volume, somatostatin analogue-associated side effects with change in HRQL. In patients with autosomal dominant polycystic kidney disease, we estimated the effect of height-adjusted kidney volume and change in kidney volume in relation to HRQL.

RESULTS

Physical component scores improved with somatostatin analogues, but remained unchanged with placebo (3.41 ± 1.29 vs. -0.71 ± 1.54, P = 0.044). Treatment had no impact on the mental component score. Large liver volume was independently associated with larger HRQL decline during follow up (-4.04 ± 2.02 points per logarithm liver volume, P = 0.049). In autosomal dominant polycystic kidney disease, patients with large liver and kidney volumes had larger decline in HRQL (5.36 ± 2.54 points per logarithm liver volume; P = 0.040 and -4.00 ± 1.88 per logarithm kidney volume; P = 0.039).

CONCLUSION

Somatostatin analogues improve HRQL in symptomatic polycystic liver disease. Halting the progressive nature of polycystic liver disease is necessary to prevent further decline of HRQL in severe hepatomegaly.

Regulation of cellular gas exchange, oxygen sensing, and metabolic control

Cells must continuously monitor and couple their metabolic requirements for ATP utilization with their ability to take up O2 for mitochondrial respiration. When O2 uptake and delivery move out of homeostasis, cells have elaborate and diverse sensing and response systems to compensate. In this review, we explore the biophysics of O2 and gas diffusion in the cell, how intracellular O2 is regulated, how intracellular O2 levels are sensed and how sensing systems impact mitochondrial respiration and shifts in metabolic pathways. Particular attention is paid to how O2 affects the redox state of the cell, as well as the NO, H2S, and CO concentrations. We also explore how these agents can affect various aspects of gas exchange and activate acute signaling pathways that promote survival. Two kinds of challenges to gas exchange are also discussed in detail: when insufficient O2 is available for respiration (hypoxia) and when metabolic requirements test the limits of gas exchange (exercising skeletal muscle). This review also focuses on responses to acute hypoxia in the context of the original "unifying theory of hypoxia tolerance" as expressed by Hochachka and colleagues. It includes discourse on the regulation of mitochondrial electron transport, metabolic suppression, shifts in metabolic pathways, and recruitment of cell survival pathways preventing collapse of membrane potential and nuclear apoptosis. Regarding exercise, the issues discussed relate to the O2 sensitivity of metabolic rate, O2 kinetics in exercise, and influences of available O2 on glycolysis and lactate production.

Increasing temperature speeds intracellular PO2 kinetics during contractions in single Xenopus skeletal muscle fibers

Precise determination of the effect of muscle temperature (T(m)) on mitochondrial oxygen consumption kinetics has proven difficult in humans, in part due to the complexities in controlling for T(m)-related variations in blood flow, fiber recruitment, muscle metabolism, and contractile properties. To address this issue, intracellular Po(2) (P(i)(O(2))) was measured continuously by phosphorescence quenching following the onset of contractions in single Xenopus myofibers (n = 24) while controlling extracellular temperature. Fibers were subjected to two identical contraction bouts, in random order, at 15°C (cold, C) and 20°C (normal, N; n = 12), or at N and 25°C (hot, H; n = 12). Contractile properties were determined for every contraction. The time delay of the P(i)(O(2)) response was significantly greater in C (59 ± 35 s) compared with N (35 ± 26 s, P = 0.01) and H (27 ± 14 s, P = 0.01). The time constant for the decline in P(i)(O(2)) was significantly greater in C (89 ± 34 s) compared with N (52 ± 15 s; P < 0.01) and H (37 ± 10 s; P < 0.01). There was a linear relationship between the rate constant for P(i)(O(2)) kinetics and T(m) (r = 0.322, P = 0.03). Estimated ATP turnover was significantly greater in H than in C (P < 0.01), but this increased energy requirement alone with increased T(m) could not account for the differences observed in P(i)(O(2)) kinetics among conditions. These results demonstrate that P(i)(O(2)) kinetics in single contracting myofibers are dependent on T(m), likely caused by temperature-induced differences in metabolic demand and by temperature-dependent processes underlying mitochondrial activation at the start of muscle contractions.

Joint prevalence and control of hypercholesterolemia and hypertension in Thailand: third national health examination survey

The prevalence, diagnosis, treatment, and control of hypercholesterolemia and/or hypertension were estimated for Thailand using data from a recent, nationally representative health examination survey. Multivariate logistic regression was used to assess factors associated with diagnosis, treatment, and control. In all, 14% of men and 17% of women had hypercholesterolemia, 23% and 21% had hypertension, and 5% and 6%, respectively, had both. A large proportion of individuals with these risk factors is neither diagnosed nor treated, let alone adequately controlled; 30% of people with hypertension had been diagnosed and 24% treated, and 9% had their blood pressure controlled. The figures for hypercholesterolemia were 13%, 9%, and 6%, respectively. Those for both risk factors combined were below 15% and did not differ by sex, urbanicity, age, or marital status. Among men, education correlated with diagnosis and treatment odds. There is great scope for improved prevention of cardiovascular disease in Thailand.

India's Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation

BACKGROUND

In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivise women to give birth in a health facility. We independently assessed the effect of JSY on intervention coverage and health outcomes.

METHODS

We used data from the nationwide district-level household surveys done in 2002-04 and 2007-09 to assess receipt of financial assistance from JSY as a function of socioeconomic and demographic characteristics; and used three analytical approaches (matching, with-versus-without comparison, and differences in differences) to assess the effect of JSY on antenatal care, in-facility births, and perinatal, neonatal, and maternal deaths.

FINDINGS

Implementation of JSY in 2007-08 was highly variable by state-from less than 5% to 44% of women giving birth receiving cash payments from JSY. The poorest and least educated women did not always have the highest odds of receiving JSY payments. JSY had a significant effect on increasing antenatal care and in-facility births. In the matching analysis, JSY payment was associated with a reduction of 3.7 (95% CI 2.2-5.2) perinatal deaths per 1000 pregnancies and 2.3 (0.9-3.7) neonatal deaths per 1000 livebirths. In the with-versus-without comparison, the reductions were 4.1 (2.5-5.7) perinatal deaths per 1000 pregnancies and 2.4 (0.7-4.1) neonatal deaths per 1000 livebirths.

INTERPRETATION

The findings of this assessment are encouraging, but they also emphasise the need for improved targeting of the poorest women and attention to quality of obstetric care in health facilities. Continued independent monitoring and evaluations are important to measure the effect of JSY as financial and political commitment to the programme intensifies.

FUNDING

Bill & Melinda Gates Foundation.

Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5

BACKGROUND

Maternal mortality remains a major challenge to health systems worldwide. Reliable information about the rates and trends in maternal mortality is essential for resource mobilisation, and for planning and assessment of progress towards Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015. We assessed levels and trends in maternal mortality for 181 countries.

METHODS

We constructed a database of 2651 observations of maternal mortality for 181 countries for 1980-2008, from vital registration data, censuses, surveys, and verbal autopsy studies. We used robust analytical methods to generate estimates of maternal deaths and the MMR for each year between 1980 and 2008. We explored the sensitivity of our data to model specification and show the out-of-sample predictive validity of our methods.

FINDINGS

We estimated that there were 342,900 (uncertainty interval 302,100-394,300) maternal deaths worldwide in 2008, down from 526,300 (446,400-629,600) in 1980. The global MMR decreased from 422 (358-505) in 1980 to 320 (272-388) in 1990, and was 251 (221-289) per 100,000 livebirths in 2008. The yearly rate of decline of the global MMR since 1990 was 1.3% (1.0-1.5). During 1990-2008, rates of yearly decline in the MMR varied between countries, from 8.8% (8.7-14.1) in the Maldives to an increase of 5.5% (5.2-5.6) in Zimbabwe. More than 50% of all maternal deaths were in only six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of the Congo). In the absence of HIV, there would have been 281 500 (243,900-327,900) maternal deaths worldwide in 2008.

INTERPRETATION

Substantial, albeit varied, progress has been made towards MDG 5. Although only 23 countries are on track to achieve a 75% decrease in MMR by 2015, countries such as Egypt, China, Ecuador, and Bolivia have been achieving accelerated progress.

FUNDING

Bill & Melinda Gates Foundation.

Measuring adult mortality using sibling survival: a new analytical method and new results for 44 countries, 1974-2006

BACKGROUND

For several decades, global public health efforts have focused on the development and application of disease control programs to improve child survival in developing populations. The need to reliably monitor the impact of such intervention programs in countries has led to significant advances in demographic methods and data sources, particularly with large-scale, cross-national survey programs such as the Demographic and Health Surveys (DHS). Although no comparable effort has been undertaken for adult mortality, the availability of large datasets with information on adult survival from censuses and household surveys offers an important opportunity to dramatically improve our knowledge about levels and trends in adult mortality in countries without good vital registration. To date, attempts to measure adult mortality from questions in censuses and surveys have generally led to implausibly low levels of adult mortality owing to biases inherent in survey data such as survival and recall bias. Recent methodological developments and the increasing availability of large surveys with information on sibling survival suggest that it may well be timely to reassess the pessimism that has prevailed around the use of sibling histories to measure adult mortality.

METHODS AND FINDINGS

We present the Corrected Sibling Survival (CSS) method, which addresses both the survival and recall biases that have plagued the use of survey data to estimate adult mortality. Using logistic regression, our method directly estimates the probability of dying in a given country, by age, sex, and time period from sibling history data. The logistic regression framework borrows strength across surveys and time periods for the estimation of the age patterns of mortality, and facilitates the implementation of solutions for the underrepresentation of high-mortality families and recall bias. We apply the method to generate estimates of and trends in adult mortality, using the summary measure (45)q(15)-the probability of a 15-y old dying before his or her 60th birthday-for 44 countries with DHS sibling survival data. Our findings suggest that levels of adult mortality prevailing in many developing countries are substantially higher than previously suggested by other analyses of sibling history data. Generally, our estimates show the risk of adult death between ages 15 and 60 y to be about 20%-35% for females and 25%-45% for males in sub-Saharan African populations largely unaffected by HIV. In countries of Southern Africa, where the HIV epidemic has been most pronounced, as many as eight out of ten men alive at age 15 y will be dead by age 60, as will six out of ten women. Adult mortality levels in populations of Asia and Latin America are generally lower than in Africa, particularly for women. The exceptions are Haiti and Cambodia, where mortality risks are comparable to many countries in Africa. In all other countries with data, the probability of dying between ages 15 and 60 y was typically around 10% for women and 20% for men, not much higher than the levels prevailing in several more developed countries.

CONCLUSIONS

Our results represent an expansion of direct knowledge of levels and trends in adult mortality in the developing world. The CSS method provides grounds for renewed optimism in collecting sibling survival data. We suggest that all nationally representative survey programs with adequate sample size ought to implement this critical module for tracking adult mortality in order to more reliably understand the levels and patterns of adult mortality, and how they are changing. Please see later in the article for the Editors' Summary.

Tobacco and hazardous or harmful alcohol use in Thailand: joint prevalence and associations with socioeconomic factors

This study estimates the individual and joint prevalence of cigarette smoking and alcohol misuse, and examines the association between these risks and socioeconomic factors in Thailand. The self-reported data on cigarette and alcohol use are from a 2004 nationally representative cross-sectional survey of 39290 individuals aged 15 and over. Substantially more men than women were current smokers (45.8% vs. 2.3%; p<0.001) as well as harmful (5.4% vs. 0.9%, p<0.0001) and hazardous alcohol users (11.2% vs. 1.2%, p<0.001). The strongest predictor of alcohol misuse was smoking, and the strongest predictor of smoking was alcohol misuse in both sexes. There was an inverse relationship between education and family income with the odds of current smoking, whereas average levels of family income (not low or high) were associated with higher odds of harmful or hazardous alcohol use. Tobacco and alcohol misuse could be more effectively addressed by targeting and tailoring programs towards those who are most at risk - joint tobacco and harmful or hazardous alcohol users, and those of lower socioeconomic status.

Trends in obesity and associations with education and urban or rural residence in Thailand

OBJECTIVE

To measure trends in the prevalence of overweight and obesity and the relationship with urban or rural residence and education in Thailand.

RESEARCH METHODS AND PROCEDURES

Data were from two nationally representative surveys of 38,323 individuals >or=18 years old (19,156 were 18 to 59 years old) in 2004 and 3375 individuals 18 to 59 years old in 1997. Overweight and obesity were defined using the World Health Organization's Asian criteria.

RESULTS

Among those >or=18 years old in 2004, 17.8% of men (95% confidence interval, 16.6% to 19.0%) were overweight, 18.4% (17.3% to 19.5%) had Class I obesity, 4.8% (4.1% to 5.5%) had Class II obesity, and 15.9% (14.6% to 17.1%) had abdominal obesity. In women, 18.2% (17.1% to 19.2%) were overweight, 26.1% (24.9% to 27.3%) had Class I obesity, 9.3% (8.6% to 10.0%) had Class II obesity, and 37.3% (35.3% to 39.2%) had abdominal obesity. In those 18 to 59 years old, the prevalence of Class I obesity in men and all four categories in women significantly increased between 1997 and 2004. There was an inverse relationship in women but a positive relationship in men between education and the odds of being overweight or obese. In 2004, there were significantly lower odds of being overweight or obese in rural compared with urban men but similar odds between urban and rural women.

DISCUSSION

The prevalence of overweight and obesity in Thailand is high and increasing. Although the transition of overweight and obesity to those of lower socioeconomic status is not complete, it is well on the way.

Improving child survival through environmental and nutritional interventions: the importance of targeting interventions toward the poor

CONTEXT

The United Nations Millennium Development Goals (MDGs) set targets related to important global poverty, health, and sustainability issues. A critical but underinvestigated question for planning and allocating resources toward the MDGs is how interventions related to one MDG might affect progress toward other goals.

OBJECTIVES

To estimate the reduction in child mortality as a result of interventions related to the environmental and nutritional MDGs (improving child nutrition and providing clean water, sanitation, and fuels) and to estimate how the magnitude and distribution of the effects of interventions vary based on the economic status of intervention recipients.

DESIGN, SETTING, AND POPULATION

Population-level comparative risk assessment modeling the mortality effects of interventions on child nutrition and environmental risk factors, stratified by economic status. Data on economic status, child underweight, water and sanitation, and household fuels were from the nationally representative Demographic and Health Surveys for 42 countries in Latin America and the Caribbean, South Asia, and sub-Saharan Africa. Data on disease-specific child mortality were from the World Health Organization. Data on the hazardous effects of each MDG-related risk factor were from systematic reviews and meta-analyses of epidemiological studies.

MAIN OUTCOME MEASURE

Child mortality, stratified by comparable international quintiles of economic status.

RESULTS

Implementing interventions that improve child nutrition and provide clean water and sanitation and clean household fuels to all children younger than 5 years would result in an estimated annual reduction in child deaths of 49,700 (14%) in Latin America and the Caribbean, 0.80 million (24%) in South Asia, and 1.47 million (31%) in sub-Saharan Africa. These benefits are equivalent to 30% to 48% of the current regional gaps toward the MDG target on reducing child mortality. Fifty percent coverage of the same environmental and nutritional interventions, as envisioned by the MDGs, would reduce child mortality by 26,900, 0.51 million, and 1.02 million in the 3 regions, respectively, if the interventions are implemented among the poor first. These reductions are 30% to 75% larger than those expected if the same 50% coverage first reached the wealthier households, who nonetheless are in need of similar interventions.

CONCLUSIONS

Interventions related to nutritional and environmental MDGs can also provide substantial gains toward the MDG of reducing child mortality. To maximize the reduction in childhood mortality, such integrated management of interventions should prioritize the poor.

Reductions in child mortality levels and inequalities in Thailand: analysis of two censuses

BACKGROUND

Thailand's progress in reducing the under-five mortality rate (U5MR) puts the country on track to achieve the fourth Millennium Development Goal (MDG). Whether this success has been accompanied by a widening or narrowing of the child mortality gap between the poorest and richest populations is unknown. We aimed to measure changes in child-mortality inequalities by household-level socioeconomic strata of the Thai population between 1990 and 2000.

METHODS

We measured changes in the distribution of the U5MR by economic strata using data from the 1990 and 2000 censuses. Economic status was measured using household assets and characteristics. The U5MR was estimated using the Trussell version of the Brass indirect method.

FINDINGS

Average household economic status improved and inequalities declined between the two censuses. There were substantially larger reductions in U5MR in the poorer segments of the population. Excess child mortality risk between the poorest and richest quintile decreased by 55% (95% CI 39% to 68%). The concentration index, measured using percentiles of economic status, in 1990 was -0.20 (-0.23 to -0.18), whereas in 2000 it had dropped to -0.12 (-0.15 to -0.08), a 43% (22% to 63%) reduction.

INTERPRETATION

These findings draw attention to the feasibility of incorporating equity measurement into census data. Thailand has achieved both an impressive average decrease in U5MR and substantial reductions in U5MR inequality over a 10 year period. Contributing factors include overall economic growth and poverty reduction, improved insurance coverage, and a scaling-up and more equitable distribution of primary health-care infrastructure and intervention coverage. Understanding the factors that have led to Thailand's success could help inform countries struggling to meet the fourth MDG and reduce inequality.

Measurement of activation energy and oxidative phosphorylation onset kinetics in isolated muscle fibers in the absence of cross-bridge cycling

This study utilized N-benzyl-p-toluene sulfonamide (BTS), a potent inhibitor of cross-bridge cycling, to measure 1) the relative metabolic costs of cross-bridge cycling and activation energy during contraction, and 2) oxygen uptake kinetics in the presence and absence of myosin ATPase activity, in isolated Xenopus laevis muscle fibers. Isometric tension development and either cytosolic Ca2+ concentration ([Ca2+]c) or intracellular Po2 (PiO2) were measured during contractions at 20 degrees C in control conditions (Con) and after exposure to 12.5 microM BTS. BTS attenuated tension development to 5+/-0.4% of Con but did not affect either resting or peak [Ca2+]c during repeated isometric contractions. To determine the relative metabolic cost of cross-bridge cycling, we measured the fall in PiO2) (DeltaPiO2; a proxy for Vo2) during contractions in Con and BTS groups. BTS attenuated DeltaP(iO2) by 55+/-6%, reflecting the relative ATP cost of cross-bridge cycling. Thus, extrapolating DeltaPiO2 to a value that would occur at 0% tension suggests that actomyosin ATP requirement is approximately 58% of overall ATP consumption during isometric contractions in mixed fiber types. BTS also slowed the fall in PiO2) (time to 63% of overall DeltaPiO2) from 75+/-9 s (Con) to 101+/-9 s (BTS) (P<0.05), suggesting an important role of the products of ATP hydrolysis in determining the Vo2 onset kinetics. These results demonstrate in isolated skeletal muscle fibers that 1) activation energy accounts for a substantial proportion (approximately 42%) of total ATP cost during isometric contractions, and 2) despite unchanged [Ca2+]c transients, a reduced rate of ATP consumption results in slower Vo2 onset kinetics.

Enhanced mitochondrial sensitivity to creatine in rats bred for high aerobic capacity

Qualitative and quantitative measures of mitochondrial function were performed in rats selectively bred 15 generations for intrinsic aerobic high running capacity (HCR; n = 8) or low running capacity (LCR; n=8). As estimated from a speed-ramped treadmill exercise test to exhaustion (15 degrees slope; initial velocity of 10 m/min, increased 1 m/min every 2 min), HCR rats ran 10 times further (2,375+/-80 m) compared with LCR rats (238+/-12 m). Fiber bundles were obtained from the soleus and chemically permeabilized. Respiration was measured 1) in the absence of ADP, 2) in the presence of a submaximally stimulating concentration of ADP (0.1 mM ADP, with and without 20 mM creatine), and 3) in the presence of a maximally stimulating concentration of ADP (2 mM). Although non-ADP-stimulated and maximally ADP-stimulated rates of respiration were 13% higher in HCR compared with LCR, the difference was not statistically significant (P>0.05). Despite a similar rate of respiration in the presence of 0.1 mM ADP, HCR rats demonstrated a higher rate of respiration in the presence of 0.1 mM ADP+20 mM creatine (HCR 33% higher vs. LCR, P<0.05). Thus mitochondria from HCR rats exhibit enhanced mitochondrial sensitivity to creatine (i.e., the ability of creatine to decrease the Km for ADP). We propose that increased respiratory sensitivity to ADP in the presence of creatine can effectively increase muscle sensitivity to ADP during exercise (when creatine is increased) and may be, in part, a contributing factor for the increased running capacity in HCR rats.

Intracellular pH during sequential, fatiguing contractile periods in isolated single Xenopus skeletal muscle fibers

The purpose of the present study was to test the hypothesis that a preceding contractile period in isolated single skeletal muscle fibers would attenuate the decrease in pH during an identical, subsequent contractile period, thereby reducing the rate of fatigue. Intact single skeletal muscle fibers ( n = 9) were isolated from Xenopus lumbrical muscle and incubated with the fluorescent cytosolic H+ indicator 2′,7′-bis-(2-carboxyethyl)-5( 6 )-carboxyfluorescein (BCECF) AM for 30 min. Two identical contractile periods were performed in each fiber, separated by a 1-h recovery period. Force and intracellular pH (pHi) fluorescence were measured simultaneously while fibers were stimulated (tetanic contractions of 350-ms trains with 70-Hz stimuli at 9 V) at progressively increasing frequencies (0.25, 0.33, 0.5, and 1 contraction/s) until the development of fatigue (to 60% initial force). No significant difference ( P < 0.05) was observed between the first and second contractile periods in initial force development, resting pHi, or time to fatigue (5.3 ± 0.5 vs. 5.1 ± 0.6 min). However, the relative decrease in the BCECF fluorescence ratio (and therefore pHi) from rest to the fatigue time point was significantly greater ( P < 0.05) during the first contractile period (to 65 ± 4% of initial resting values) compared with the second (77 ± 4%). The results of the present study demonstrated that, when preceded by an initial fatiguing contractile period, the rise in cytosolic H+ concentration in contracting single skeletal muscle fibers during a second contractile period was significantly reduced but did not attenuate the fatigue process in the second contractile period. These results suggest that intracellular factors other than H+ accumulation contribute to the fall in force development under these conditions.

Trimetazidine reduces basal cytosolic Ca2+ concentration during hypoxia in single Xenopus skeletal myocytes

We tested the hypotheses that: (1) Ca(2+) handling and force production would be irreversibly altered in skeletal muscle during steady-state contractions when subjected to severe, prolonged hypoxia and subsequent reoxygenation; and (2) application of the cardio-protective drug trimetazidine would attenuate these alterations. Single, living skeletal muscle fibres from Xenopus laevis were injected with the Ca(2+) indicator fura 2, and incubated for 1 h prior to stimulation in 100 micro M TMZ-Ringer solution (TMZ; n = 6) or standard Ringer solution (CON; n = 6). Force and relative free cytosolic Ca(2+) concentration ([Ca(2+)](c)) were measured during continuous tetanic contractions produced every 5 s as fibres were sequentially perfused in the following manner: 3 min high extracellular P(O(2)) (159 mmHg), 15 min hypoxic perfusion (3-5 mmHg) then 3 min high P(O(2)). Hypoxia caused a decrease in force and peak [Ca(2+)](c) in both the TMZ and CON fibres, with no significant (P < 0.05) difference between groups. However, basal [Ca(2+)](c) was significantly lower during hypoxia in the TMZ group vs. the CON group. While reoxygenation generated only modest recovery of relative force and peak [Ca(2+)](c) in both groups, basal [Ca(2+)](c) remained significantly less in the TMZ group. These results demonstrated that in contracting, single skeletal muscle fibres, TMZ prevented increases in basal [Ca(2+)](c) generated during a severe hypoxic insult and subsequent reoxygenation, yet failed to protect the cell from the deleterious effects of prolonged hypoxia followed by reoxygenation.

Response of Wegener's granulomatosis to anti-CD20 chimeric monoclonal antibody therapy

We report on the successful, compassionate use of the anti-CD20 chimeric monoclonal antibody rituximab in a patient with chronic, relapsing cytoplasmic antineutrophil cytoplasmic antibody (cANCA)-associated Wegener's granulomatosis (WG). The patient initially responded to treatment with glucocorticoids and cyclophosphamide. However, bone marrow toxicity during cyclophosphamide treatment of a relapse precluded its further use. Azathioprine and mycophenolate mofetil treatment had failed to maintain remission of the WG, and methotrexate was contraindicated. Because the patient's 5-year course was characterized by close correlation of cANCA levels with disease activity, selective elimination of cANCA was deemed a treatment option for his latest relapse. He was given 4 infusions of 375 mg/M2 of rituximab and high-dose glucocorticoids. Complete remission was associated with the disappearance of B lymphocytes and cANCA. Glucocorticoid treatment was then discontinued. After 11 months, the cANCA recurred, and rituximab therapy was repeated, without glucocorticoids. At 8 months after the second course of rituximab (18 months after the first course), the patient's WG has remained in complete remission. Elimination of B cells by rituximab therapy may prove to be an effective and safe new treatment modality for ANCA-associated vasculitis and possibly other autoimmune diseases. This modality warrants closer examination in a carefully conducted clinical trial.

Two cases of non-O157:H7 Escherichia coli hemolytic uremic syndrome caused by urinary tract infection

Escherichia coli serotype O157:H7 is a leading cause of diarrhea and hemolytic uremic syndrome (HUS). Because of the limitations of current diagnostic techniques, the prevalence of non-O157:H7 Shiga toxin-producing E coli strains is not known. We describe two patients with HUS in whom no E coli O157:H7 was demonstrable in stool cultures. On culture of the urine, the first patient was found to have E coli O113:H21 strain, and the second patient had E coli O6:H1 serotype. Shiga toxin production (stx2) by the O113:H21 isolate was confirmed. The first patient required 15 days of peritoneal dialysis and subsequently recovered renal function. At last follow-up, serum creatinine was 0.9 mg/dL. The second patient had preservation of renal function throughout the acute illness with serum creatinine of 0.5 mg/dL. The clinical presentation, bacteriology, course, and outcome as well as epidemiologic implications of the increasing number of patients with E coli urinary tract infections associated with HUS are discussed. These cases illustrate the need to investigate patients with nondiarrheal HUS for infection with Shiga toxin-producing E coli of the non-O157 strain variety.

Intracellular PO(2) decreases with increasing stimulation frequency in contracting single Xenopus muscle fibers

There is currently some controversy regarding the manner in which skeletal muscle intracellular PO(2) changes with work intensity. Therefore, this study investigated the relationship between intracellular PO(2) and stimulation frequency in intact, isolated, single skeletal muscle fibers. Single, living muscle fibers (n = 7) were microdissected from the lumbrical muscles of Xenopus and injected with the oxygen-sensitive probe palladium-meso-tetra(4-carboxyphenyl)porphine (0.5 mM). Fibers were mounted with platinum clips to a force transducer in a chamber, which was continuously perfused with Ringer solution (pH = 7.0) at a PO(2) of approximately 30 Torr. Fibers were then stimulated sequentially for 3 min, followed by a 3-min rest, at each of five contraction frequencies (0.15, 0.2, 0.25, 0.33, and 0.5 Hz), in a random order, using tetanic contractions. Resting intracellular PO(2) averaged 31.2 +/- 0.9 Torr. During steady-state stimulation, intracellular PO(2) declined to 21.2 +/- 2.3, 17.1 +/- 2.4, 15.3 +/- 1.9, 9.8 +/- 2.0, and 5.8 +/- 1.4 Torr for 0.15, 0.2, 0.25, 0.33, and 0.5-Hz stimulation, respectively. Significant fatigue, as defined by a decrease in force to <50% of the initial force, occurred only at the highest (0.5 Hz) stimulation frequency in five of the cells and at 0.33 Hz in the other two. Regression analysis demonstrated that there was a significant (P < 0.0001, r = 0.82) negative correlation between intracellular PO(2) and contraction frequency in these isolated, single cells. The linear decrease in intracellular PO(2) with stimulation frequency, and thus energy demand, suggests that a fall in intracellular PO(2) correlates with increased oxygen uptake in these single contracting cells.

Preconditioning improves function and recovery of single muscle fibers during severe hypoxia and reoxygenation

Reperfusion following prolonged ischemia induces cellular damage in whole skeletal muscle models. Ischemic preconditioning attenuates the deleterious effects. We tested whether individual skeletal muscle fibers would be similarly affected by severe hypoxia and reoxygenation (H/R) in the absence of extracellular factors and whether cellular damage could be alleviated by hypoxic preconditioning. Force and free cytosolic Ca2+ ([Ca2+]c) were monitored in Xenopus single muscle fibers (n = 24) contracting tetanically at 0.2 Hz during 5 min of severe hypoxia and 5 min of reoxygenation. Twelve cells were preconditioned by a shorter bout of H/R 1 h before the experimental trial. In preconditioned cells, force relative to initial maximal values (P/P(o)) and relative peak [Ca2+]c fell (P < 0.05) during 5 min of hypoxia and recovered during reoxygenation. In contrast, P/P(o) and relative peak [Ca2+]c fell more during hypoxia (P < 0.05) and recovered less during reoxygenation (P < 0.05) in control cells. The ratio of force to [Ca2+]c was significantly higher in the preconditioned cells during severe hypoxia, suggesting that changes in [Ca2+]c were not solely responsible for the loss in force. We conclude that 1) isolated skeletal muscle fibers contracting in the absence of extracellular factors are susceptible to H/R injury associated with changes in Ca2+ handling; and 2) hypoxic preconditioning improves contractility, Ca2+ handling, and cell recovery during subsequent hypoxic insult.

Recovery of force during postcontractile depression in single Xenopus muscle fibers

This study examined the relationship between force and cytosolic free calcium concentration ([Ca2+]c) in different fiber types from Xenopus before, during, and after cells underwent postcontractile depression (PCD). During a standardized fatigue run, force in the two fast fatiguing (FF) fiber types (types 1 and 2, n = 10) fell more quickly (5.8 vs. 8.1 min) and to a greater degree [0.36 vs. 0.51 of initial (P(o))] than in the slow fatiguing (SF) fiber type (type 3, n = 11). After the initial fatigue run, both FF and SF experienced a drop in force to <15% P(o) (PCD) at a similar time (20.6 vs. 21.4 min). A second stimulation period, undertaken during PCD, produced significant recovery of force in both groups, but significantly more so in SF than FF (64 +/- 7 vs. 29 +/- 2% P(o)). This force recovery during PCD was accompanied by a significant increase in peak [Ca2+]c, particularly in SF. However, despite the significant recovery of force during stimulation while in PCD, the amount of force produced for a given peak [Ca2+]c was significantly lower in both groups during PCD than at any other point in the experiment. A final stimulation period, initiated when all fibers had recovered from PCD, demonstrated a recovery of both force and peak [Ca2+]c in both groups, but this recovery was significantly greater in SF vs. FF. These data demonstrate that with continuous electrical stimulation, it is possible to produce a significant recovery of force production during the normally quiescent period of PCD, but that it occurs with a decreased muscle force production for a given peak [Ca2+]c. This suggests that factors other than structural alterations of the sarcoplasmic reticulum are likely the cause of PCD in these fibers.

Fall in intracellular PO(2) at the onset of contractions in Xenopus single skeletal muscle fibers

It remains uncertain whether the delayed onset of mitochondrial respiration on initiation of muscle contractions is related to O(2) availability. The purpose of this research was to measure the kinetics of the fall in intracellular PO(2) at the onset of a contractile work period in rested and previously worked single skeletal muscle fibers. Intact single skeletal muscle fibers (n = 11) from Xenopus laevis were dissected from the lumbrical muscle, injected with an O(2)-sensitive probe, mounted in a glass chamber, and perfused with Ringer solution (PO(2) = 32 +/- 4 Torr and pH = 7.0) at 20 degrees C. Intracellular PO(2) was measured in each fiber during a protocol consisting sequentially of 1-min rest; 3 min of tetanic contractions (1 contraction/2 s); 5-min rest; and, finally, a second 3-min contractile period identical to the first. Maximal force development and the fall in force (to 83 +/- 2 vs. 86 +/- 3% of maximal force development) in contractile periods 1 and 2, respectively, were not significantly different. The time delay (time before intracellular PO(2) began to decrease after the onset of contractions) was significantly greater (P < 0.01) in the first contractile period (13 +/- 3 s) compared with the second (5 +/- 2 s), as was the time to reach 50% of the contractile steady-state intracellular PO(2) (28 +/- 5 vs. 18 +/- 4 s, respectively). In Xenopus single skeletal muscle fibers, 1) the lengthy response time for the fall in intracellular PO(2) at the onset of contractions suggests that intracellular factors other than O(2) availability determine the on-kinetics of oxidative phosphorylation and 2) a prior contractile period results in more rapid on-kinetics.

Role of convective O(2) delivery in determining VO(2) on-kinetics in canine muscle contracting at peak VO(2)

A previous study (Grassi B, Gladden LB, Samaja M, Stary CM, and Hogan MC, J Appl Physiol 85: 1394-1403, 1998) showed that convective O(2) delivery to muscle did not limit O(2) uptake (VO(2)) on-kinetics during transitions from rest to contractions at approximately 60% of peak VO(2). The present study aimed to determine whether this finding is also true for transitions involving contractions of higher metabolic intensities. VO(2) on-kinetics were determined in isolated canine gastrocnemius muscles in situ (n = 5) during transitions from rest to 4 min of electrically stimulated isometric tetanic contractions corresponding to the muscle peak VO(2). Two conditions were compared: 1) spontaneous adjustment of muscle blood flow (Q) (Control) and 2) pump-perfused Q, adjusted approximately 15-30 s before contractions at a constant level corresponding to the steady-state value during contractions in Control (Fast O(2) Delivery). In Fast O(2) Delivery, adenosine was infused intra-arterially. Q was measured continuously in the popliteal vein; arterial and popliteal venous O(2) contents were measured at rest and at 5- to 7-s intervals during the transition. Muscle VO(2) was determined as Q times the arteriovenous blood O(2) content difference. The time to reach 63% of the VO(2) difference between resting baseline and steady-state values during contractions was 24.9 +/- 1.6 (SE) s in Control and 18.5 +/- 1.8 s in Fast O(2) Delivery (P < 0.05). Faster VO(2) on-kinetics in Fast O(2) Delivery was associated with an approximately 30% reduction in the calculated O(2) deficit and with less muscle fatigue. During transitions involving contractions at peak VO(2), convective O(2) delivery to muscle, together with an inertia of oxidative metabolism, contributes in determining the VO(2) on-kinetics.

Impairment of Ca(2+) release in single Xenopus muscle fibers fatigued at varied extracellular PO(2)

We tested the hypothesis that the mechanisms involved in the more rapid onset of fatigue when O(2) availability is reduced in contracting skeletal muscle are similar to those when O(2) availability is more sufficient. Two series of experiments were performed in isolated, single skeletal muscle fibers from Xenopus laevis. First, relative force and free cytosolic Ca(2+) concentrations ([Ca(2+)](c)) were measured simultaneously in single fibers (n = 6) stimulated at increasing frequencies (0.25, 0.33, 0.5, and 1 Hz) at an extracellular PO(2) of either 22 or 159 Torr. Muscle fatigue (force = 50% of initial peak tension) occurred significantly sooner (P < 0.05) during the low- (237 +/- 40 s) vs. high-PO(2) treatments (280 +/- 38 s). Relative [Ca(2+)](c) was significantly decreased from maximal values at the fatigue time point during both the high- (72 +/- 4%) and low-PO(2) conditions (78 +/- 4%), but no significant difference was observed between the treatments. In the second series of experiments, using the same stimulation regime as the first, fibers (n = 6) exposed to 5 mM caffeine immediately after fatigue demonstrated an immediate but incomplete relative force recovery during both the low- (89 +/- 4%) and high-PO(2) treatments (82 +/- 3%), with no significant difference between treatments. Additionally, there was no significant difference in relative [Ca(2+)](c) between the high- (100 +/- 12% of prefatigue values) and low-PO(2) treatments (108 +/- 12%) on application of caffeine. These results suggest that in isolated, single skeletal muscle fibers, the earlier onset of fatigue that occurred during the low-extracellular PO(2) condition was modulated through similar pathways as the fatigue process during the high and involved a decrease in relative peak [Ca(2+)](c).

Phosphorylating pathways and fatigue development in contracting Xenopus single skeletal muscle fibers

To investigate the differential contribution of oxidative and substrate-level phosphorylation to force production during repetitive, maximal tetanic contractions, single skeletal muscle fiber performance was examined under conditions of high-oxygen availability and anoxia. Tetanic force development (P) was measured in isolated, single type-1 muscle fibers (fast twitch; n = 6) dissected from Xenopus lumbrical muscle while being stimulated at increasing frequencies (0.25, 0.33, and 0.5 Hz), with each frequency lasting 2 min. Two separate work bouts were conducted, with the perfusate PO(2) being either 0 or 159 mmHg. No significant (P < 0. 05) difference was found in the initial peak tensions (P(0)) between the high (334 +/- 57 kPa) and the low (325 +/- 41 kPa) PO(2) treatment. No significant difference in P was observed between the treatments during the first 50 s. However, a significant difference in force production was observed between the high (P/P(0) = 0.96 +/- 0.02) and the low PO(2) condition (P/P(0) = 0.92 +/- 0.02) by 60 s of work. After 60 s, steady-state force production was maintained during the high compared with the low PO(2) condition until stimulation frequency was increased, at which point developed tension during the high PO(2) condition began to decline. Time to fatigue (P/P(0) = 0.3) was reached significantly sooner during the low (250 +/- 16 s) than the high PO(2) condition (367 +/- 28 s). These results demonstrate that during the first 50 s of 0.25-Hz contractions, substrate-level phosphorylation has the capacity to maintain force and ATP hydrolysis when oxidative phosphorylation is absent. This period was followed by an oxygen-dependent phase in which force generation was maintained during the high PO(2) condition (but not during the low PO(2) condition) until the onset of a final fatiguing phase, at which a calculated maximal rate of oxidative phosphorylation was reached.

Structural basis of muscle O(2) diffusing capacity: evidence from muscle function in situ

Although evidence for muscle O(2) diffusion limitation of maximal O(2) uptake has been found in the intact organism and isolated muscle, its relationship to diffusion distance has not been examined. Thus we studied six sets of three purpose-bred littermate dogs (aged 10-12 mo), with 1 dog per litter allocated to each of three groups: control (C), exercise trained for 8 wk (T), or left leg immobilized for 3 wk (I). The left gastrocnemius muscle from each animal was surgically isolated, pump-perfused, and electrically stimulated to peak O(2) uptake at three randomly applied levels of arterial oxygenation [normoxia, arterial PO(2) (Pa(O(2))) 77 +/- 2 (SE) Torr; moderate hypoxia, Pa(O(2)): 33 +/- 1 Torr; and severe hypoxia, Pa(O(2)): 22 +/- 1 Torr]. O(2) delivery (ml. min(-1). 100 g(-1)) was kept constant among groups for each level of oxygenation, with O(2) delivery decreasing with decreasing Pa(O(2)). O(2) extraction (%) was lower in I than T or C for each condition, but calculated muscle O(2) diffusing capacity (Dmus(O(2))) per 100 grams of muscle was not different among groups. After the experiment, the muscle was perfusion fixed in situ, and a sample from the midbelly was processed for microscopy. Immobilized muscle showed a 45% reduction of muscle fiber cross-sectional area (P < 0.05), and a resulting 59% increase in capillary density (P < 0.05) but minimal reduction in capillary-to-fiber ratio (not significant). In contrast, capillarity was not significantly different in T vs. C muscle. The results show that a dramatically increased capillary density (and reduced diffusion distance) after short-term immobilization does not improve Dmus(O(2)) in heavily working skeletal muscle.

All-trans-retinoic acid-induced myositis: a description of two patients

All-trans-retinoic acid (ATRA) induces complete clinical remissions in a high proportion of patients with acute promyelocytic leukemia and has become the standard induction therapy. Its use as a single agent results in short-lived remissions; thus, cytotoxic drugs are used for "consolidation" therapy. Side effects reported during treatment with ATRA include retinoic acid syndrome and Sweet's syndrome. Sweet's syndrome has been associated with acute myelogenous leukemia at presentation, but only two cases of Sweet's syndrome involving the musculoskeletal system in patients treated with ATRA have been described. We describe two additional patients with acute promyelocytic leukemia who had unexplained fever and myalgias (cutaneous lesions in one patient) during induction therapy with ATRA. Radiologic findings were similar to those in previously reported ATRA-associated Sweet's syndrome of the musculoskeletal system. The clinical course was characterized by a rapid resolution of the symptoms during treatment with dexamethasone. Recognition of the syndrome is important, especially considering the rapid resolution of symptoms after early institution of therapy with corticosteroids.

Rapid force recovery in contracting skeletal muscle after brief ischemia is dependent on O(2) availability

We tested the hypothesis that contracting skeletal muscle can rapidly restore force development during reperfusion after brief total ischemia and that this rapid recovery depends on O(2) availability and not an alternate factor related to blood flow. Isolated canine gastrocnemius muscle (n = 5) was stimulated to contract tetanically (isometric contraction elicited by 8 V, 0.2-ms duration, 200-ms trains, at 50-Hz stimulation) every 2 s until steady-state conditions of muscle blood flow (controlled by pump perfusion) and developed force were attained (3 min). While maintaining the same stimulation pattern, muscle blood flow was then reduced to zero (complete ischemia) for 2 min. Normal blood flow was then restored to the contracting muscle; however, two distinct conditions of oxygenation (at the same blood flow) were sequentially imposed: deoxygenated blood (30 s), blood with normal arterial O(2) content (30 s), a return to deoxygenated blood (30 s), and finally a return to normal arterial O(2) content (90 s). During the ischemic period, force development fell to 39 +/- 6 (SE)% of normal (from 460 +/- 40 to 170 +/- 20 N/100 g). When muscle blood flow was restored to normal by perfusion with deoxygenated blood, developed force continued to decline to 140 +/- 20 N/100 g. Muscle force rapidly recovered to 310 +/- 30 N/100 g (P < 0.05) during the 30 s in which the contracting muscle was perfused with oxygenated blood and then fell again to 180 +/- 30 N/100 g when perfused with blood with low PO(2). These findings demonstrate that contracting skeletal muscle has the capacity for rapid recovery of force development during reperfusion after a short period of complete ischemia and that this recovery depends on O(2) availability and not an alternate factor related to blood flow restoration.

Double pulse transthoracic defibrillation in the calf using percent fibrillation cycle length as spacing determinate

Recent studies have found that when multiple pulses of energy are used for defibrillation with implantable electrodes, the spacing between these pulses is better determined as a percentage of the fibrillation cycle length (CL), rather than as a fixed function of time. Here, this concept is further tested in the transthoracic defibrillation of calves, which are approximately the size of heavy humans. Eleven 90-110 kg calves (101 +/- 6 kg) were used in evaluating the effectiveness in achieving transthoracic ventricular defibrillation of ten double pulse waveforms (two 50 A 4-ms rectangular monopulses) having leading edge-to-edge spacings of 4 ms (a 50 A 8-ms rectangular monopulse) and 50, 60, 70, 80, 90, 100, 110, 120, 130 percent fibrillation CL, respectively. In each of these waveforms, the total time when 50 A current was flowing (on time) was 8 ms. Our results show an unequivocal adverse interaction between the pulses, when the spacing is around 60%-70% fibrillation CL; but that the two pulses combined to defibrillate as effectively as a single 8-ms pulse when the spacing is around 110%-130% fibrillation CL. Electrocardiographic analysis suggests that the adverse interaction is due to a refibrillation phenomenon. This study confirms that double pulses can interact and have a negative effect on defibrillation efficacy. Our data suggests that the mechanism of this interaction involves the second pulse reinitiating fibrillation when the pulse separation is in a critical range of values. Our results are also compatible with the hypothesis that the spacing of multiple pulses is better determined as a percentage of the fibrillation CL than as absolute time, although more study is necessary to fully test this hypothesis.

Skeletal muscle phosphocreatine recovery in exercise-trained humans is dependent on O2 availability

In skeletal muscle, phosphocreatine (PCr) recovery from submaximal exercise has become a reliable and accepted measure of muscle oxidative capacity. During exercise, O2 availability plays a role in determining maximal oxidative metabolism, but the relationship between O2 availability and oxidative metabolism measured by 31P-magnetic resonance spectroscopy (MRS) during recovery from exercise has never been studied. We used 31P-MRS to study exercising human gastrocnemius muscle under conditions of varied fractions of inspired O2 (FIO2) to test the hypothesis that varied O2 availability modulates PCr recovery from submaximal exercise. Six male subjects performed three bouts of 5-min steady-state submaximal plantar flexion exercise followed by 5 min of recovery in a 1.5-T magnet while breathing three different FIO2 concentrations (0.10, 0. 21, and 1.00). Under each FIO2 treatment, the PCr recovery time constants were significantly different, being longer in hypoxia [33. 5 +/- 4.1 s (SE)] and shorter in hyperoxia (20.0 +/- 1.8 s) than in normoxia (25.0 +/- 2.7 s) (P </= 0.05). End-exercise pH was not significantly different among the three treatments (7.08 +/- 0.01 for 0.10, 7.04 +/- 0.01 for 0.21, and 7.04 +/- 0.02 for 1.00). These results demonstrate that PCr recovery is significantly altered by FIO2 and suggest that, after submaximal exercise, PCr recovery, under normoxic conditions, is limited by O2 availability.

Effect of varied extracellular PO2 on muscle performance in Xenopus single skeletal muscle fibers

The purpose of this study was to examine the development of fatigue in isolated, single skeletal muscle fibers when O2 availability was reduced but not to levels considered rate limiting to mitochondrial respiration. Tetanic force was measured in single living muscle fibers (n = 6) from Xenopus laevis while being stimulated at increasing contraction rates (0.25, 0.33, 0.5, and 1 Hz) in a sequential manner, with each stimulation frequency lasting 2 min. Muscle fatigue (determined as 75% of initial maximum force) was measured during three separate work bouts (with 45 min of rest between) as the perfusate PO2 was switched between values of 30 +/- 1.9, 76 +/- 3.0, or 159 Torr in a blocked-order design. No significant differences were found in the initial peak tensions between the high-, intermediate-, and low-PO2 treatments (323 +/- 22, 298 +/- 27, and 331 +/- 24 kPa, respectively). The time to fatigue was reached significantly sooner (P < 0.05) during the 30-Torr treatment (233 +/- 39 s) compared with the 76- (385 +/- 62 s) or 159-Torr (416 +/- 65 s) treatments. The calculated critical extracellular PO2 necessary to develop an anoxic core within these fibers was 13 +/- 1 Torr, indicating that the extracellular PO2 of 30 Torr should not have been rate limiting to mitochondrial respiration. The magnitude of an unstirred layer (243 +/- 64 micron) or an intracellular O2 diffusion coefficient (0.45 +/- 0.04 x 10(-5) cm2/s) necessary to develop an anoxic core under the conditions of the study was unlikely. The earlier initiation of fatigue during the lowest extracellular PO2 condition, at physiologically high intracellular PO2 levels, suggests that muscle performance may be O2 dependent even when mitochondrial respiration is not necessarily compromised.

Human muscle performance and PCr hydrolysis with varied inspired oxygen fractions: a 31P-MRS study

The purpose of this study was to use 31P-magnetic resonance spectroscopy to examine the relationships among muscle PCr hydrolysis, intracellular H+ concentration accumulation, and muscle performance during incremental exercise during the inspiration of gas mixtures containing different fractions of inspired O2 (FIO2). We hypothesized that lower FIO2 would result in a greater disruption of intracellular homeostasis at submaximal workloads and thereby initiate an earlier onset of fatigue. Six subjects performed plantar flexion exercise on three separate occasions with the only variable altered for each exercise bout being the FIO2 (either 0.1, 0.21, or 1.00 O2 in balance N2). Work rate was increased (1-W increments starting at 0 W) every 2 min until exhaustion. Time to exhaustion (and thereby workload achieved) was significantly (P < 0.05) greater as FIO2 was increased. Muscle phosphocreatine (PCr) concentration, Pi concentration, and pH at exhaustion were not significantly different among the three FIO2 conditions. However, muscle PCr concentration and pH were significantly reduced at identical submaximal workloads (and thereby equivalent rates of respiration) above 4-5 W during the lowest FIO2 condition compared with the other two FIO2 conditions. These results demonstrate that exhaustion during all FIO2 occurred when a particular intracellular environment was achieved and suggest that during the lowest FIO2 condition, the greater PCr hydrolysis and intracellular acidosis at submaximal workloads may have contributed to the significantly earlier time to exhaustion.

Phosphorescence quenching method for measurement of intracellular PO2 in isolated skeletal muscle fibers

Values of skeletal muscle intracellular PO2 during conditions ranging from rest to maximal metabolic rates have been difficult to quantify. A method for measurement of intracellular PO2 in isolated single skeletal muscle fibers by using O2-dependent quenching of a phosphorescent-O2 probe is described. Intact single skeletal muscle fibers from Xenopus laevis were dissected from the lumbrical muscle and mounted in a glass chamber containing Ringer solution at 20 degreesC. The chamber was placed on the stage of an inverted microscope configured for epi-illumination. A solution containing palladium-meso-tetra (4-carboxyphenyl) porphine bound to bovine serum albumin was injected into single fibers by micropipette pressure injection. Phosphorescence-decay curves (average of 10 rapid flashes) were recorded every 7 s from single cells (n = 24) in which respiration had been eliminated with NaCN, while the PO2 of the Ringer solution surrounding the cell was varied from 0 to 159 Torr. For each measurement, the phosphorescence lifetime was calculated at the varied extracellular PO2 by obtaining a best-fit estimate by using a monoexponential function. The phosphorescence lifetime varied from 40 to 70 microseconds at an extracellular PO2 of 159 Torr to 650-700 microseconds at 0 Torr. The phosphorescent lifetimes for the varied PO2 were used to calculate, by using the Stern-Volmer relationship, the phosphorescence-quenching constant (100 Torr-1. s-1), and the phosphorescence lifetime in a zero-O2 environment (690 microseconds) for the phosphor within the intracellular environment. This technique demonstrates a novel method for determining intracellular PO2 in isolated single skeletal muscle fibers.

Differential depression of myocardial function and metabolism by lactate and H+

The effects of both high blood H+ concentration ([H+]) and high blood lactate concentration ([lactate]) under ischemia-reperfusion conditions are receiving attention, but little is known about their effects in nonischemic hearts. Isolated rat hearts were Langendorff perfused at constant flow with media at two pH values (7.4 and 7.0) and two [lactate] (0 and 20 mM) in various sequences (n = 6/group). Coronary flow and arterial O2 content were kept constant at levels that allowed hearts to function without O2 supply limitation. We measured contractility, O2 uptake, diastolic pressure, and at the end of the protocol, tissue [lactate] and pH. Perfusion with high [lactate] raised tissue [lactate] from 5.5 +/- 0.1 to 17.5 +/- 2.6 micromol/heart (P < 0.0001), whereas decreasing the pH of the medium decreased tissue pH from 6.94 +/- 0.02 to 6.81 +/- 0.06 (P = 0.002). Heart rate was not affected by high [lactate] but was reversibly depressed by high [H+] (P = 0.004). Developed pressure declined by 20% in response to high [lactate], high [H+], and high [lactate] + high [H+] (P = 0.002). After the high-[lactate] challenge was withdrawn, pressure continued to decline. In contrast, withdrawing the high [H+] challenge allowed partial recovery. The behavior of diastolic pressure mirrored that of developed pressure. Although unaffected by high [lactate], the O2 uptake was reversibly depressed by high [H+]. This suggests higher O2 cost per contraction in the presence of high [lactate]. We conclude that for similar acute contractility depression, high [lactate] induces irreversible damage, likely at some point in the pathway of O2 utilization. In contrast, the effect of high [H+] appears reversible. These differential behaviors may have implications for heart function during heavy exercise and ischemia-reperfusion events.

Phosphocreatine hydrolysis during submaximal exercise: the effect of FIO2

There is evidence that the concentration of the high-energy phosphate metabolites may be altered during steady-state submaximal exercise by the breathing of different fractions of inspired O2 (FIO2). Whereas it has been suggested that these changes may be the result of differences in time taken to achieve steady-state O2 uptake (V(O2)) at different FIO2 values, we postulated that they are due to a direct effect of O2 tension. We used 31P-magnetic resonance spectroscopy during constant-load, steady-state submaximal exercise to determine 1) whether changes in high-energy phosphates do occur at the same V(O2) with varied FIO2 and 2) that these changes are not due to differences in V(O2) onset kinetics. Six male subjects performed steady-state submaximal plantar flexion exercise [7.2 +/- 0.6 (SE) W] for 10 min while lying supine in a 1.5-T clinical scanner. Magnetic resonance spectroscopy data were collected continuously for 2 min before exercise, 10 min during exercise, and 6 min during recovery. Subjects performed three different exercise bouts at constant load with the FIO2 switched after 5 min of the 10-min exercise bout. The three exercise treatments were 1) FIO2 of 0.1 switched to 0.21, 2) FIO2 of 0.1 switched to 1.00, and 3) FIO2 of 1.00 switched to 0.1. For all three treatments, the FIO2 switch significantly (P </= 0.05) altered phosphocreatine: 1) 55.5 +/- 4.8 to 67.8 +/- 4.9% (%rest); 2) 59.0 +/- 4.3 to 72.3 +/- 5.1%; and 3) 72.6 +/- 3.1 to 64.2 +/- 3.4%, respectively. There were no significant differences in intracellular pH for the three treatments. The results demonstrate that the differences in phosphocreatine concentration with varied FIO2 are not the result of different V(O2) onset kinetics, as this was eliminated by the experimental design. These data also demonstrate that changes in intracellular oxygenation, at the same work intensity, result in significant changes in cell homeostasis and thereby suggest a role for metabolic control by O2 even during submaximal exercise.

Faster adjustment of O2 delivery does not affect V(O2) on-kinetics in isolated in situ canine muscle

The mechanism(s) limiting muscle O2 uptake (VO2) kinetics was investigated in isolated canine gastrocnemius muscles (n = 7) during transitions from rest to 3 min of electrically stimulated isometric tetanic contractions (200-ms trains, 50 Hz; 1 contraction/2 s; 60-70% of peak V(O2)). Two conditions were mainly compared: 1) spontaneous adjustment of blood flow (Q) [control, spontaneous Q (C Spont)]; and 2) pump-perfused Q, adjusted approximately 15 s before contractions at a constant level corresponding to the steady-state value during contractions in C Spont [faster adjustment of O2 delivery (Fast O2 Delivery)]. During Fast O2 Delivery, 1-2 ml/min of 10(-2) M adenosine were infused intra-arterially to prevent inordinate pressure increases with the elevated Q. The purpose of the study was to determine whether a faster adjustment of O2 delivery would affect V(O2) kinetics. Q was measured continuously; arterial (Ca(O2)) and popliteal venous (Cv(O2)) O2 contents were determined at rest and at 5- to 7-s intervals during contractions; O2 delivery was calculated as Q x Ca(O2), and V(O2) was calculated as Q x arteriovenous O2 content difference. Times to reach 63% of the difference between baseline and steady-state VO2 during contractions were 23.8 +/- 2.0 (SE) s in C Spont and 21.8 +/- 0.9 s in Fast O2 Delivery (not significant). In the present experimental model, elimination of any delay in O2 delivery during the rest-to-contraction transition did not affect muscle V(O2) kinetics, which suggests that this kinetics was mainly set by an intrinsic inertia of oxidative metabolism.

Peripheral O2 diffusion does not affect V(O2)on-kinetics in isolated insitu canine muscle

To test the hypothesis that muscle O2 uptake (V(O2)) on-kinetics is limited, at least in part, by peripheral O2 diffusion, we determined the V(O2) on-kinetics in 1) normoxia (Control); 2) hyperoxic gas breathing (Hyperoxia); and 3) hyperoxia and the administration of a drug (RSR-13, Allos Therapeutics), which right-shifts the Hb-O2 dissociation curve (Hyperoxia+RSR-13). The study was conducted in isolated canine gastrocnemius muscles (n = 5) during transitions from rest to 3 min of electrically stimulated isometric tetanic contractions (200-ms trains, 50 Hz; 1 contraction/2 s; 60-70% peak V(O2)). In all conditions, before and during contractions, muscle was pump perfused with constantly elevated blood flow (Q), at a level measured at steady state during contractions in preliminary trials with spontaneous Q x Adenosine was infused intra-arterially to prevent inordinate pressure increases with the elevated Q x Q was measured continuously, arterial and popliteal venous O2 concentrations were determined at rest and at 5- to 7-s intervals during contractions, and V(O2) was calculated as Q x arteriovenous O2 content difference. PO2 at 50% HbO2 saturation (P50) was calculated. Mean capillary PO2 (Pc(O2)) was estimated by numerical integration. P50 was higher in Hyperoxia+RSR-13 [40 +/- 1 (SE) Torr] than in Control and in Hyperoxia (31 +/- 1 Torr). After 15 s of contractions, Pc(O2) was higher in Hyperoxia (97 +/- 9 Torr) vs. Control (53 +/- 3 Torr) and in Hyperoxia+RSR-13 (197 +/- 39 Torr) vs. Hyperoxia. The time to reach 63% of the difference between baseline and steady-state V(O2) during contractions was 24.7 +/- 2.7 s in Control, 26.3 +/- 0.8 s in Hyperoxia, and 24.7 +/- 1.1 s in Hyperoxia+RSR-13 (not significant). Enhancement of peripheral O2 diffusion (obtained by increased PcO2 at constant O2 delivery) during the rest-to-contraction (60-70% of peak V(O2)) transition did not affect muscle V(O2) on- kinetics.

Bioenergetics of contracting skeletal muscle after partial reduction of blood flow

The purpose of this study was to examine the bioenergetics and regulation of O2 uptake (VO2) and force production in contracting muscle when blood flow was moderately reduced during a steady-state contractile period. Canine gastrocnemius muscle (n = 5) was isolated, and 3-min stimulation periods of isometric, tetanic contractions were elicited sequentially at rates of 0.25, 0.33, and 0.5 contractions/s (Hz) immediately followed by a reduction of blood flow [ischemic (I) condition] to 46 +/- 3% of the value obtained at 0.5 Hz with normal blood flow. The VO2 of the contracting muscle was significantly (P < 0.05) reduced during the I condition [6.5 +/- 0.8 (SE) ml . 100 g-1 . min-1] compared with the same stimulation frequency with normal flow (11.2 +/- 1.5 ml . 100 g-1 . min-1), as was the tension-time index (79 +/- 12 vs. 123 +/- 22 N . g-1 . min-1, respectively). The ratio of VO2 to tension-time index remained constant throughout all contraction periods. Muscle phosphocreatine concentration, ATP concentration, and lactate efflux were not significantly different during the I condition compared with the 0. 5-Hz condition with normal blood flow. However, at comparable rates of VO2 and tension-time index, muscle phosphocreatine concentration and ATP concentration were significantly less during the I condition compared with normal-flow conditions. These results demonstrate that, in this highly oxidative muscle, the normal balance of O2 supply to force output was maintained during moderate ischemia by downregulation of force production. In addition, 1) the minimal disruption in intracellular homeostasis after the initiation of ischemia was likely a result of steady-state metabolic conditions having already been activated, and 2) the difference in intracellular conditions at comparable rates of VO2 and tension-time index between the normal flow and I condition may have been due to altered intracellular O2 tension.

Contraction duration affects metabolic energy cost and fatigue in skeletal muscle

It has been suggested that during a skeletal muscle contraction the metabolic energy cost at the onset may be greater than the energy cost related to holding steady-state force. The purpose of the present study was to investigate the effect of contraction duration on the metabolic energy cost and fatigue process in fully perfused contracting muscle in situ. Canine gastrocnemius muscle (n = 6) was isolated, and two contractile periods (3 min of isometric, tetanic contractions with 45-min rest between) were conducted by each muscle in a balanced order design. The two contractile periods had stimulation patterns that resulted in a 1:3 contraction-to-rest ratio, with the difference in the two contractile periods being in the duration of each contraction: short duration 0.25-s stimulation/0.75-s rest vs. long duration 1-s stimulation/3-s rest. These stimulation patterns resulted in the same total time of stimulation, number of stimulation pulses, and total time in contraction for each 3-min period. Muscle O2 uptake, the fall in developed force (fatigue), the O2 cost of developed force, and the estimated total energy cost (ATP utilization) of developed force were significantly greater (P < 0.05) with contractions of short duration. Lactate efflux from the working muscle and muscle lactate concentration were significantly greater with contractions of short duration, such that the calculated energy derived from glycolysis was three times greater in this condition. These results demonstrate that contraction duration can significantly affect both the aerobic and anaerobic metabolic energy cost and fatigue in contracting muscle. In addition, it is likely that the greater rate of fatigue with more rapid contractions was a result of elevated glycolytic production of lactic acid.

Leptospirosis in the Republic of Ireland: 1985 to 1996

Official government statistics and serological laboratory data provide limited information about the incidence of leptospirosis in the Republic of Ireland. The mean annual notified incidence in the Republic of Ireland from 1985 to 1996 was 1.3/million. The incidence according to hospital discharge diagnosis was higher at 4.9/million. One hundred and seventy-five serologically confirmed cases of leptospirosis were reported from 1986 to 1996, giving a mean annual incidence of 4.5/million. The true incidence of leptospirosis in the Republic of Ireland is probably higher, as hospital discharge data are incomplete and full serological testing was not always performed. Our data indicate that leptospirosis is an underestimated public health problem with only 26% of cases being notified. A national communicable disease surveillance centre in the Republic of Ireland would facilitate better monitoring and understanding of this disease.

Effect of inspired O2 concentration on leg lactate release during incremental exercise

The normal rate of blood lactate accumulation during exercise is increased by hypoxia and decreased by hyperoxia. It is not known whether these changes are primarily determined by the lactate release in locomotory muscles or other tissues. Eleven men performed cycle exercise at 20, 35, 50, 92, and 100% of maximal power output while breathing 12, 21, and 100% O2. Leg lactate release was calculated at each stage of exercise as the product of femoral venous blood flow (thermodilution method) and femoral arteriovenous difference in blood lactate concentrations. Regression analysis showed that leg lactate release accounted for 90% of the variability in mean arterial lactate concentration at 20-92% maximal power output. This relationship was described by a regression line with a slope of 0.28 +/- 0.02 min/l and a y-intercept of 1.06 +/- 0.38 mmol/l (r2 = 0.90). There was no effect of inspired O2 concentration on this relationship (P > 0.05). We conclude that during continuous incremental exercise to fatigue the effect of inspired O2 concentration on blood lactate accumulation is principally determined by the rate of net lactate release in blood vessels of the locomotory muscles.

Blood flow distribution in working in situ canine muscle during blood flow reduction

The purpose of this study was to determine whether reduction in apparent muscle O2 diffusing capacity (Dmo2) calculated during reduced blood flow conditions in maximally working muscle is a reflection of alterations in blood flow distribution. Isolated dog gastrocnemius muscle (n = 6) was stimulated for 3 min to achieve peak O2 uptake (VO2) at two levels of blood flow (controlled by pump perfusion): control (C) conditions at normal perfusion pressure (blood flow = 111 +/- 10 ml.100 g-1.min-1) and reduced blood flow treatment [ischemia (I); 52 +/- 6 ml.100 g-1.min-1]. In addition, maximal vasodilation was achieved by adenosine (A) infusion (10(-2)M) at both levels of blood flow, so that each muscle was subjected randomly to a total of four conditions (C, CA, I, and IA; each separated by 45 min of rest). Muscle blood flow distribution was measured with 15-microns-diameter colored microspheres. A numerical integration technique was used to calculate Dmo2 for each treatment with use of a model that calculates O2 loss along a capillary on the basis of Fick's law of diffusion. Peak VO2 was reduced significantly (P < 0.01) with ischemia and was unchanged by adenosine infusion at either flow rate (10.6 +/- 0.9, 9.7 +/- 1.0, 6.7 +/- 0.2, and 5.9 +/- 0.8 ml.100 g-1.min-1 for C, CA, I, and IA, respectively). Dmo2 was significantly lower by 30-35% (P < 0.01) when flow was reduced (except for CA vs. I; 0.23 +/- 0.03, 0.20 +/- 0.02, 0.16 +/- 0.01, and 0.13 +/- 0.01 ml.100 g-1.min-1.Torr-1 for C, CA, I, and IA, respectively). As expressed by the coefficient of variation (0.45 +/- 0.04, 0.47 +/- 0.04, 0.55 +/- 0.03, and 0.53 +/- 0.04 for C, CA, I, and IA, respectively), blood flow heterogeneity per se was not significantly different among the four conditions when examined by analysis of variance. However, there was a strong negative correlation (r = 0.89, P < 0.05) between Dmo2 and blood flow heterogeneity among the four conditions, suggesting that blood flow redistribution (likely a result of a decrease in the number of perfused capillaries) becomes an increasingly important factor in the determination of Dmo2 as blood flow is diminished.

Effect of gradual reduction in O2 delivery on intracellular homeostasis in contracting skeletal muscle

This study was designed to investigate 1) whether a protocol employing a gradual reduction in O2 availability to submaximally contracting muscle results in relatively minor disturbances in intracellular homeostasis and 2) the interaction between tissue oxygenation and the proposed regulators of muscle respiration, metabolism, and force production. O2 delivery to isolated submaximally contracting [isometric contractions at 3 Hz; approximately 50% of peak O2 uptake (VO2)] in situ canine gastrocnemius (n = 6) was manipulated by decreasing arterial PO2 (hypoxemia; H) or muscle blood flow (ischemia; I) during three separate periods in each muscle [control (C), H, or I; each separated by 45 min of rest]. O2 delivery was reduced gradually in small steps every 3 min by H or I during two of the contraction periods (6 steps for a total of 21 min; O2 delivery reduced by 67% by the end of 21 min), whereas C was at normal O2 delivery for a 15-min period. Muscle VO2 was maintained at control levels for the first two O2 delivery reduction steps for the H and I conditions and then fell proportionally with O2 delivery to approximately 35% of the initial value by the end of the 21-min contraction period. Muscle force development generally fell in parallel with VO2. There was no significant changes from the values obtained during C contractions in intracellular concentrations of ATP, phosphocreatine, NH3, calculated free ADP, lactate, and redox state ratios as the O2 delivery was reduced, even with the severe decline in VO2 and developed force. These results demonstrated that when O2 availability was reduced gradually to contracting skeletal muscle, 1) developed force (ATP utilization) was reduced through a tight coupling with aerobic ATP supply, such that there was little additional disruption of intracellular homeostasis, and 2) there was an apparent dissociation of some of the proposed regulators of cell respiration and force development from the control of these processes.

Effect of [Hb] on blood flow distribution and O2 transport in maximally working skeletal muscle

We investigated whether the reduction in calculated muscle diffusion capacity for O2 (DmO2) previously shown to occur with lowered hemoglobin concentration ([Hb]) perfusion of maximally working muscle is related to changes in the blood flow distribution. If blood flow distribution is altered during low [Hb] conditions, the reduction in the calculated DmO2 may in fact be due to increasing heterogeneity and not to some other hemoglobin-related factor. Color-stained (15-microns-diam) microspheres were injected into the artery supplying maximally working isolated in situ dog gastrocnemius muscle (n = 6) while it was being perfused (flow controlled by pump perfusion) with whole blood at three different levels of [Hb] (14.1 +/- 0.5, 8.9 +/- 0.4, and 5.7 +/- 0.4 (SE) g/100 ml] in a blocked-order design. Muscle blood flow and arterial PO2 were not changed as [Hb] was altered. Maximal O2 uptake (11.8 +/- 1.3, 8.2 +/- 0.8, and 6.0 +/- 0.9 ml.100 g-1 min-1 for those [Hb] values, respectively) and the associated estimate of DmO2 (0.25 +/- 0.03, 0.18 +/- 0.03, and 0.15 +/- 0.03 ml.100 g-1.min-1.Torr-1) declined significantly (P < 0.05) with [Hb]. However, the dispersion of the blood flow distribution did not change significantly and, if anything, indicated less heterogeneity at lower [Hb] (coefficient of variation - 0.52 +/- 0.06, 0.46 +/- 0.05, and 0.43 +/- 0.03). These results suggest that in maximally working canine muscle in situ, when O2 delivery is reduced by lowering [Hb] (at constant blood flow), changes in blood flow distribution play no significant role in the reduction of maximal O2 uptake and calculated DmO2. The apparent increase in the resistance to O2 diffusion (i.e., reduction in the DmO2) during anemia may therefore be a result of increased red blood cell spacing in the capillary, slow chemical off-loading kinetics of O2 from Hb, or some other effect that remains to be determined.