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In this study, we investigate adaptations in muscle oxidative capacity, fiber size and oxygen supply capacity in team-sport athletes after six repeated-sprint sessions in normobaric hypoxia or normoxia combined with 14 days of chronic normobaric hypoxic exposure. Lowland elite field hockey players resided at simulated altitude (≥14 h/day at 2,800–3,000 m) and performed regular training plus six repeated-sprint sessions in normobaric hypoxia (3,000 m; LHTLH; n = 6) or normoxia (0 m; LHTL; n = 6) or lived at sea level with regular training only (LLTL; n = 6). Muscle biopsies were obtained from the m. vastus lateralis before (pre), immediately after (post-1), and 3 wk after the intervention (post-2). Changes over time between groups were compared, including likelihood of the effect size (ES). Succinate dehydrogenase activity in LHTLH largely increased from pre to post-1 (~35%), likely more than LHTL and LLTL (ESs = large-very large), and remained elevated in LHTLH at post-2 (~12%) vs. LHTL (ESs = moderate-large). Fiber cross-sectional area remained fairly similar in LHTLH from pre to post-1 and post-2 but was increased at post-1 and post-2 in LHTL and LLTL (ES = moderate-large). A unique observation was that LHTLH and LHTL, but not LLTL, improved their combination of fiber size and oxidative capacity. Small-to-moderate differences in oxygen supply capacity (i.e., myoglobin and capillarization) were observed between groups. In conclusion, elite team-sport athletes substantially increased their skeletal muscle oxidative capacity, while maintaining fiber size, after only 14 days of chronic hypoxic residence combined with six repeated-sprint training sessions in hypoxia. NEW & NOTEWORTHY Our novel findings show that elite team-sport athletes were able to substantially increase the skeletal muscle oxidative capacity in type I and II fibers (+37 and +32%, respectively), while maintaining fiber size after only 14 days of chronic hypoxic residence combined with six repeated-sprint sessions in hypoxia. This increase in oxidative capacity was superior to groups performing chronic hypoxic residence with repeated sprints in normoxia and residence at sea level with regular training only.

A major problem in chronic heart failure is the inability of hypertrophied cardiomyocytes to maintain the required power output. A Hill-type oxygen diffusion model predicts that oxygen supply is limiting in hypertrophied cardiomyocytes at maximal rates of oxygen consumption and that this limitation can be reduced by increasing the myoglobin (Mb) concentration. We explored how cardiac hypertrophy, oxidative capacity, and Mb expression in right ventricular cardiomyocytes are regulated at the transcriptional and translational levels in an early stage of experimental pulmonary hypertension, in order to identify targets to improve the oxygen supply/demand ratio. Male Wistar rats were injected with monocrotaline to induce pulmonary hypertension (PH) and right ventricular heart failure. The messenger RNA (mRNA) expression levels per nucleus of growth factors insulin-like growth factor-1Ea (IGF-1Ea) and mechano growth factor (MGF) were higher in PH than in healthy controls, consistent with a doubling in cardiomyocyte cross-sectional area (CSA). Succinate dehydrogenase (SDH) activity was unaltered, indicating that oxidative capacity per cell increased. Although the Mb protein concentration was unchanged, Mb mRNA concentration was reduced. However, total RNA per nucleus was about threefold higher in PH rats versus controls, and Mb mRNA content expressed per nucleus was similar in the two groups. The increase in oxidative capacity without an increase in oxygen supply via Mb-facilitated diffusion caused a doubling of the critical extracellular oxygen tension required to prevent hypoxia (PO2crit). We conclude that Mb mRNA expression is not increased during pressure overload-induced right ventricular hypertrophy and that the increase in myoglobin content per myocyte is likely due to increased translation. We conclude that increasing Mb mRNA expression may be beneficial in the treatment of experimental PH.

The aims of this study were to assess the prevalence of iron deficiency in idiopathic pulmonary arterial hypertension (IPAH) and investigate whether oral iron supplementation has effects in iron-deficient patients. Iron parameters were measure for all IPAH patients attending our centre (VU University Medical Center, Amsterdam, the Netherlands) between May 2009 and February 2010. Iron data were related to clinical parameters, including 6-min walking distance (6MWD), and haemodynamic parameters measured during right heart catheterisation. In a subset of iron-deficient patients, the uptake of iron from the bowel was studied after administering oral iron for 4 weeks. Iron deficiency was found in 30 (43%) out of 70 patients. 6MWD was reduced in iron-deficient patients compared with iron-sufficient patients (mean±sd 390±138 versus 460±143 m; p

Background— Exercise training in pulmonary arterial hypertension (PH) is a promising adjunct to medical treatment. However, it is still unclear whether training is beneficial for all PH patients. We hypothesized that right ventricular adaptation plays a pivotal role in the response to training. Methods and Results— Two different dosages of monocrotaline were used in rats to model stable PH with preserved cardiac output and progressive PH developing right heart failure. Two weeks after injection, PH was confirmed by echocardiography, and treadmill training was initiated. Rats were trained for 4 weeks unless manifest right heart failure developed earlier. At the end of the study protocol, all rats were functionally assessed by endurance testing, echocardiography, and invasive pressure measurements. Lungs and hearts were further analyzed in quantitative histomorphologic analyses. In stable PH, exercise training was well tolerated and markedly increased exercise endurance (from 25±3.9 to 62±3.9 minutes; P P 2 ; P Conclusions— In our rat model, exercise training was found to be beneficial in stable PH but detrimental in progressive PH. Future studies are necessary to address the clinical implications of our findings.

The aim of this study was to investigate effects of albumin and insulin separately as well as in combination on mature muscle fibres during long-term culture. Single muscle fibres were dissected from m. iliofibularis of Xenopus laevis and attached to a force transducer in a culture chamber. Fibres were cultured in a serum-free medium at slack length (mean sarcomere length 2.3 mum) for 8 to 22 days. The medium was supplemented with (final concentrations): (1) bovine insulin (6 nmol/L or 200-600 nmol/L), (2) 0.2% bovine albumin or (3) 0.2% bovine albumin in combination with insulin (120 nmol/L). In culture medium with insulin, 50% of the muscle fibres became in-excitable within 7-12 days, whereas the other 50% were stable. Caffeine contractures of in-excitable muscle fibres produced 80.4 +/- 2.4% of initial peak tetanic force, indicating impaired excitation-contraction (E-C) coupling in in-excitable fibres. In the presence of albumin, all cultured muscle fibres were stable for at least 10 days. Muscle fibres cultured in medium with insulin or albumin exclusively did not hypertrophy or change the number of sarcomeres in series. In contrast, muscle fibres cultured with both albumin and insulin showed an increase in tetanic force and fibre cross-sectional area of 19.6 +/- 2.8% and 32.5 +/- 4.9%, respectively, (means +/- SEM.; P = 0.007) after 16.3 +/- 1.7 days, whereas the number of sarcomeres in series remained unchanged. We conclude that albumin prevents muscle fibre damage and preserves E-C coupling in culture. Furthermore, albumin is important in regulating muscle fibre adaptation by a synergistic action with growth factors like insulin.

The aims of this study were (1) to determine the relationship between muscle fibre cross-sectional area and cytoplasmic density of myonuclei in high- and low-oxidative Xenopus muscle fibres and (2) to test whether insulin and long-term high fibre length caused an increase in the number of myonuclei and in the expression of α-skeletal actin and of myogenic regulatory factors (myogenin and MyoD) in these muscle fibres. In high- and low-oxidative muscle fibres from freshly frozen iliofibularis muscles, the number of myonuclei per millimetre fibre length was proportional to muscle fibre cross-sectional area. The in vivo myonuclear density thus seemed to be strictly regulated, suggesting that the induction of hypertrophy required the activation of satellite cells. The effects of muscle fibre length and insulin on myonuclear density and myonuclear mRNA content were investigated on high-oxidative single muscle fibres cultured for 4-5 days. Muscle fibres were kept at a low length (∼15% below passive slack length) in culture medium with a high insulin concentration (∼6 nmol/l: "high insulin medium") or without insulin, and at a high length (∼5% above passive slack length) in high insulin medium. High fibre length and high insulin medium did not change the myonuclear density of isolated muscle fibres during culture. High insulin increased the myonuclear α-skeletal actin mRNA content, whereas fibre length had no effect on α-skeletal actin mRNA content. After culture at high fibre length in high insulin medium, the myonuclear myogenin mRNA content was 2.5-fold higher than that of fibres cultured at low length in high insulin medium or in medium without insulin. Myonuclear MyoD mRNA content was not affected by fibre length or insulin. These in vitro experiments indicate that high muscle fibre length and insulin enhance muscle gene expression but that other critical factors are required to induce adaptation of muscle fibre size and performance. © 2006 Springer-Verlag.

Oxygen supply and demand of individual cardiomyocytes during the development of myocardial hypertrophy is studied using calibrated histochemical methods. An oxygen diffusion model is used to calculate the critical extracellular oxygen tension (PO2,crit) required by cardiomyocytes to prevent hypoxia during hypertrophic growth, and determinants of PO2,crit are estimated using calibrated histochemical methods for succinate dehydrogenase activity, cardiomyocyte cross-sectional area, and myoglobin concentration. The model calculation demonstrates that it is essential to calibrate the histochemical methods, so that absolute values for the relevant parameters are obtained. The succinate dehydrogenase activity, which is proportional to the maximum rate of oxygen consumption, and the myoglobin concentration hardly change while the cardiomyocytes grow. The cross-sectional area of the cardiomyocytes, which increases up to threefold in the right ventricular wall due to pulmonary hypertension in monocrotaline-treated rats, is the most important determinant of PO2,crit in this model of myocardial hypertrophy. The relationship between oxygen supply and demand at the level of the cardiomyocyte can be investigated using paired determinations of spatially integrated succinate dehydrogenase activity and capillary density. Hypoxia-inducible factor 1α can be demonstrated by immunohistochemistry in cardiomyocytes with high PO2,crit and increased spatially integrated succinate dehydrogenase activity, indicating that limited oxygen supply affects gene expression in these cells. We conclude that a mismatch of oxygen supply and demand may develop during hypertrophic growth, which can play a role in the transition from myocardial hypertrophy to heart failure. Microsc. Res. Tech. 58:412–420, 2002. © 2002 Wiley-Liss, Inc.

In this study alterations are characterized which occur, in myocardial force development morphological appearance and protein composition, during the development of cardiac hypertrophy and heart failure in monocrotaline (MCT) treated rats. The transition from cardiac hypertrophy to heart failure was studied by comparing the results from control (CON) and two MCT groups (40 and 44 mg/kg body weight). The three experimental groups consisted of at least five animals each. Parameters studied were: body weight (measured daily), lung/body weight ratio, right ventricular wall volume and thickness, and force development in thin right ventricular trabeculae at 27°C, using different extracellular calcium concentrations and pacing frequencies. MCT injection resulted in marked right ventricular hypertrophy and heart failure as evidenced by an up to 2-fold increase in lung/body weight ratio and a 1.7-fold increase in wall volume. The MCT groups showed a negative force–frequency relation and maximum force was up to 2-fold less than in the CON group. Protein analysis by means of one- and two-dimensional gel electrophoresis revealed a marked (7-fold) up-regulation of the slow myosin heavy chain isoform as well as a 4.5-fold increase in the content of the cytoskeletal protein desmin, whereas the mitochondrial protein ATP-synthase content was reduced. Hence MCT-induced cardiac hypertrophy and heart failure result in altered cellular calcium handling, depression of maximum force output, an increase in the economy of myocardial contraction and changes in cytoskeletal structure and energy supply.

Oxygen consumption and heat production were measured during contraction and recovery of isolated, white muscle fibres from dogfish (Scyliorhinus canicula) at 19 degrees C. The contraction period consisted of 20 isometric twitches at 3 Hz; this was followed by a recovery period of 2 h without stimulation. We tested the hypothesis that recovery is wholly oxidative (not glycolytic) in these fibres. The following features support this hypothesis. (i) The ratio of total heat produced to oxygen consumed, 451+/−34 kJ mol(−)(1) (mean +/− s.e.m., N=29), was close to that expected for either the oxidation of carbohydrate, 473 kJ mol(−)(1), or the oxidation of fat, 439 kJ mol(−)(1). Even assuming the maximum value (95 % confidence limit) of the observed heat production, glycolysis could account for resynthesis of at most 18 % of the ATP used during the contractions. (ii) When the difference in rates of diffusion of oxygen and heat within the muscle are taken into account, the time courses of oxygen consumption and heat production match each other well during the entire recovery period. The efficiency of recovery (=energy used for ATP synthesis/energy available for ATP synthesis) was estimated from the results. This value, 84.0+/−20.1 % (mean +/− s.e.m., N=29), is relatively high and represents the first such measurement in functioning muscle.

It is known that a range of firing frequencies can be observed during in vivo muscle activity, yet information is lacking as to how different in vivo-like frequencies may affect force generation of skeletal muscle. This study examined the effects of constant (CSF, constant within one contraction) and decreasing stimulation frequencies (DSF) on mean sarcomere length-force characteristics of rat gastrocnemius medialis fibre bundles. The CSF resulted in an optimal mean sarcomere length (lso) of 2.30 (SEM 0.02), 2.46 (SEM 0.03), 2.76 (SEM 0.03) and more than 2.99 (SEM 0.07) lm, for 100, 50, 30 and 15 Hz, respectively. Compared to 100-Hz stimulation, both lso and the ascending limb of the relationship significantly shifted to higher lengths with lower frequencies. No shift was encountered for the initial part of the descending limb. The DSF reduced the frequency-induced shift to higher mean lengths [lso 2.33 (SEM 0.02), 2.52 (SEM 0.08) and more than 2.92 (SEM 0.10) microm, respectively, for 50, 30 and 15 Hz]. No effect of activation time on length-force characteristics was observed. It was concluded from these studies that the frequency and history of stimulation is a major determinant of the length-force characteristics of muscle fibre bundles, and should be taken into account when analysing animal and human locomotion. The previously observed frequency-induced shift in whole muscle length-force relationship resides mainly at the level of fibre bundles.

The present study was designed in order to investigate more precisely the role of calcium homeostasis maintenance in protein kinase C (PKC) mediated preconditioning. We used a 15 min pre-incubation period, with 1 mumol/l exogenous norepinephrine (NE) to pharmacologically precondition isolated, superfused rat trabeculae against contractile dysfunctioning following 120 min of metabolic inhibition (MI, in 2 mmol/l CN- containing Tyrode without glucose at 1 Hz stimulation frequency). Contractile recovery was studied during a subsequent 60 min recovery period (RP, in glucose containing Tyrode at 0.2 Hz). Tyrode was gassed with 95%, O2/ 5% CO2 and kept at a constant temperature of 24 degrees C. Force and intracellular free calcium ([Ca2+]i) were monitored throughout the experimental protocol; [Ca2+]i was measured using fura-2. Pretreatment with NE (group NE-I) significantly increased the fraction of trabeculae that resumed to contract during RP, from 36 +/- 13% (mean +/- S.E.M.) in controls to 82 +/- 10% (P0.05). In correspondence with this, NE-pretreatment increased the proportion of trabeculae in which the Ca2+ rise from the onset of rigor development during MI was attenuated. After 40 min of MI [Ca2+]i in the failing control, as well as failing group NE-I, trabeculae (1.08 +/- 0.20 and 1.51 +/- 0.26 mumol/l, respectively) was increased significantly compared to the mean value registered in the recovering preparations of these groups (0.34 +/- 0.04 mumol/l: P0.05). Specific inhibition of PKC with 2 mumol/l chelerythrine (group NE-IV) almost completely blocked the protection induced by NE-pretreatment, including its protective action against Ca2+ overload, i.e. the fraction of trabeculae that resumed to contract during RP returned to untreated control level (46 +/- 11%: P0.05 v group NE-I). Also in this case [Ca2+]i in the failing group NE-IV trabeculae after 40 min of MI was increased substantially, compared to the value measured in the recovering preparations (4.75 +/- 1.00 and 0.60 +/- 0.08 mumol/ l, respectively). The relative importance of both alpha-adrenergic and beta-adrenergic receptor pathways in this preconditioning-like effect of NE-pretreatment, was investigated using specific blockers. The results point to an alpha 1-adrenergic receptor mediated signaling mechanism, which enhances PKC-dependent control of [Ca2+]i from the onset of rigor development during MI.

The origin of the threefold variation found previously in isometric force normalized to cross-sectional area of single fast-twitch tibialis anterior muscle fibres of the frog Rana temporaria was studied by using (1) a strictly defined stimulus protocol, and (2) influencing the condition of the frog using artificial hibernation. Variation in normalized force was found to be influenced by the length of the rest period between tetani. After a long rest (>6 h), tetanic force production was less than for a tetanus produced after 1 h. The length of the rest period accounted for a factor of 1.24 of the total variation in normalized force. The condition of the frog also influenced normalized force production. Little variation in normalized force was observed between different fibres from the same animal, whereas a significant difference was found between animals. After artificial hibernation, force normalized to cross-sectional area remained unchanged, but force normalized to dry mass per unit length increased; the total variation increased from a factor of 1.37 to a factor of 1.64. Force normalized to muscle protein mass per unit length, however, was not affected by artificial hibernation. We conclude that variation in normalized tetanic force can be partly reduced by standardization of the stimulation protocol and normalization to protein content per unit length.

1. The origin of labile heat production, i.e. a heat component which rapidly decays after the onset of stimulation, and of stable (maintenance) heat production was investigated in intact single fast-twitch (type 1) and slow-twitch (type 3) iliofibularis muscle fibres from Xenopus laevis, at 20 degrees C, by varying stimulation frequency and by varying sarcomere length and the concentration of 2,3-butanedione 2-monoxime (BDM) added. 2. The labile heat produced consisted of a force-independent and a force-dependent part. The average parvalbumin (PA) content found in type 1 fibre bundles (0.84 +/- 0.08 mM; mean +/- S.E.M.; n = 5) and in type 3 fibre bundles (0.12 +/- 0.02 mM; n = 5) indicates that the force-independent labile heat is explained by Ca(2+)-Mg2+ exchange on PA, and amounts to a molar enthalpy change of -78 kJ (molPA)-1. 3. Force-dependent labile heat during fused contractions was similar to the calculated heat production resulting from the formation of force-generating cross-bridges, assuming an enthalpy change associated with cross-bridge formation of -30 kJ mol-1. 4. Activation heat, i.e. the part of the total stable heat that is not related to the contractile apparatus, and of which the calcium sequestration by the sarcoplasmic reticulum is the most important contributor, determined by varying sarcomere length or BDM concentration, was identical. For fused contractions the fraction activation heat of the stable maintenance rate of heat production was 34 +/- 4% (mean +/- S.E.M.; n = 13) in type 1 fibres, and 52 +/- 4% (n = 15) in type 3 fibres. In unfused contractions this was 48 +/- 5% (n = 13) in type 1 fibres, and 35 +/- 2% (n = 11) in type 3 fibres. 5. From the force-dependent stable rate of heat production the economy of cross-bridge cycling, expressed as the force-time integral for a single myosin head per ATP molecule hydrolysed, was calculated. It followed that cross-bridge interaction in type 3 fibres is more economical than in type 1 fibres, and that fused contractions are more economical than unfused contractions.

To study how sarcomere length inhomogeneities and the duration of activation affect sarcomere length-force characteristics of muscle, the mean sarcomere length-force relationship was determined for twitches and at 100 and 300 ms during tetanic activation for rat extensor digitorum longus and gastrocnemius medialis muscle fibre bundles. Mean sarcomere length is the mean length of all sarcomeres within the fibre, calculated by dividing fibre length by the number of sarcomeres in series in the fibre. The twitch mean sarcomere length-force relationship is shifted to larger sarcomere lengths (optimum mean sarcomere length = 2.69 microns) compared to the relationships determined at 100 or 300 ms of tetanic activation (optimum mean sarcomere length = 2.38 microns), which were the same. It is shown that the normalized Gordon et al. rationale results in a large overestimate of force (at most 68% of force at a sarcomere length of 1.60 microns) for mean sarcomere lengths between 1.4 and 2.0 microns, and in an underestimate of force between 2.3 and 3.0 microns. It is concluded that modelling skeletal mammalian muscle length-force relationships can be improved by using mean sarcomere length-force relations of mammalian fibres instead of the normalized rationale of Gordon et al. derived from a selected homogeneous part of frog fibre.

This report describes the development of a histochemical method for the demonstration of sarcoplasmic reticulum Ca-ATPase activity in cross-sections of skeletal muscle. The demonstration of sarcoplasmic reticulum Ca-ATPase activity is complicated by the fact that capturing reagents for phosphate inhibit the enzyme. We present a minimal model for heavy-metal-phosphate precipitation reactions which gives a theoretical description of the effect of enzyme inhibition on the rate of phosphate precipitation in the section. The model indicates that the choice of capturing reagent is crucial: whether or not ATPase activity can be demonstrated depends mainly on the inhibition constant and the solubility product of the phosphate salt of the capturing reagent (but also on a fairly large number of other factors). All lanthanides tested can be used to demonstrate sarcoplasmic reticulum Ca-ATPase activity, but dysprosium results in the highest staining intensity. This suggests that dysprosium inhibits sarcoplasmic reticulum Ca-ATPase to a lesser degree than the other lanthanides and/or the solubility product of its phosphate salt is smaller. As an example, the method is used to investigate the effect of thyroid hormone on sarcoplasmic reticulum Ca-ATPase activity in individual fibres of the rat soleus muscle.

1. Isolated, fast-twitch, low-oxidative muscle fibres from the iliofibularis muscle of Xenopus laevis were fatigued by intermittent tetanic stimulation at 20 degrees C in different Ringer solutions and the amount of lactate released was determined. 2. The rate of lactate efflux was constant during 10 min of intermittent stimulation while lactate in the fibres accumulated, and lactate efflux was not hampered by an unstirred layer surrounding the isolated muscle fibre. 3. The rate of lactate efflux at extracellular pH 7.2 was the same as that at pH 7.8, but depended on the type of buffer used; the highest efflux rate (mean +/- S.E.M., 7.4 +/- 2.2 mumol min-1 (g dry weight)-1, n = 8) was observed in bicarbonate-buffered Ringer solution. This rate was about 2.5 times higher than the rate in phosphate-buffered Ringer solution (2.9 +/- 1.3 mumol min-1 (g dry weight)-1, n = 8), indicating that lactate-bicarbonate exchange is the most important route for lactate extrusion in vivo. 4. The highest rate of lactate efflux corresponds to a rate of glycolytic ATP production which is only about 30% of the oxidative rate of ATP production (calculated from the maximum rate of oxygen consumption determined previously). 5. In the presence of 5 mM alpha-cyano-4-hydroxycinnamate (CHC) the lowest lactate efflux rate (1.5 +/- 0.6 mumol min-1 (g dry weight)-1, n = 16) was found. This rate was independent of the composition of the Ringer solution. Assuming that 5 mM CHC completely inhibits lactate transporters in the sarcolemma, the rate of lactate efflux in the presence of 5 mM CHC can be explained by passive diffusion, but only if most lactate is extruded via the T-tubules.

Pulmonary arterial hypertension (PAH) still cannot be cured, warranting the search for novel treatments. Fasudil (a Rho kinase inhibitor) was compared with bosentan (an endothelin receptor blocker) and sildenafil (a phosphodiesterase 5 inhibitor), with emphasis on right ventricular (RV) function, in a reversal rat model of monocrotaline (MCT)-induced PAH. In addition, the effects of combining bosentan or sildenafil with fasudil were studied. MCT (40 mg·kg body weight(-1)) induced clear PAH in male Wistar rats (n = 9). After 28 days, echocardiography, RV catheterisation and histochemistry showed that cardiac frequency, stroke volume and RV contractility had deteriorated, accompanied by RV dilatation and hypertrophy, and marked pulmonary arterial wall thickening. Mean pulmonary arterial pressure and pulmonary vascular resistance increased significantly compared to healthy rats (n = 9). After 14 days, MCT-treated rats received a 14-day oral treatment with bosentan, sildenafil, fasudil or a combination of fasudil with either bosentan or sildenafil (all n = 9). All treatments preserved cardiac frequency, stroke volume and RV contractility, and reduced pulmonary vascular resistance and RV dilatation. Fasudil lowered RV systolic pressure and mean pulmonary arterial pressure significantly, by reducing pulmonary arterial remodelling, which reduced RV hypertrophy. Combining bosentan or sildenafil with fasudil had no synergistic effect. Fasudil significantly improved PAH, to a greater degree than did bosentan and sildenafil.

An inverse relationship exists between striated muscle fiber size and its oxidative capacity. This relationship implies that muscle fibers, which are triggered to simultaneously increase their mass/strength (hypertrophy) and fatigue resistance (oxidative capacity), increase these properties (strength or fatigue resistance) to a lesser extent compared to fibers increasing either of these alone. Muscle fiber size and oxidative capacity are determined by the balance between myofibrillar protein synthesis, mitochondrial biosynthesis and degradation. New experimental data and an inventory of critical stimuli and state of activation of the signaling pathways involved in regulating contractile and metabolic protein turnover reveal: (1) higher capacity for protein synthesis in high compared to low oxidative fibers; (2) competition between signaling pathways for synthesis of myofibrillar proteins and proteins associated with oxidative metabolism; i.e., increased mitochondrial biogenesis via AMP-activated protein kinase attenuates the rate of protein synthesis; (3) relatively higher expression levels of E3-ligases and proteasome-mediated protein degradation in high oxidative fibers. These observations could explain the fiber type–fiber size paradox that despite the high capacity for protein synthesis in high oxidative fibers, these fibers remain relatively small. However, it remains challenging to understand the mechanisms by which contractile activity, mechanical loading, cellular energy status and cellular oxygen tension affect regulation of fiber size. Therefore, one needs to know the relative contribution of the signaling pathways to protein turnover in high and low oxidative fibers. The outcome and ideas presented are relevant to optimizing treatment and training in the fields of sports, cardiology, oncology, pulmonology and rehabilitation medicine. Electronic supplementary material The online version of this article (doi:10.1007/s00421-010-1545-0) contains supplementary material, which is available to authorized users.

1. Peak isometric force of single fast (type 1) and slow (type 3) muscle fibres of Xenopus decreased when fibres were stimulated intermittently above their predicted sustainable duty cycle at 20 degrees C. Type 1 fibres could be fatigued to zero force. In most type 3 fibres force did not decrease below 50% of the original (P0) before activation failure, as indicated by irregular contractions. 2. Fibres were rapidly frozen at different force levels and analysed by high-performance liquid chromatography (HPLC) for ATP, IMP, phosphocreatine (PCr) and creatine (Cr). Lactate was determined enzymatically in type 1 fibres only. The relationships between force and PCr, and between force and ATP during fatigue were, apart from the range of values obtained, the same for both fibre types. When force had fallen to about 60-80% of original, PCr was fully reduced. At lower force levels, the ATP content-decreased, and a concomitant rise of IMP content was found. At zero force, ATP had fallen to about 25% of its value in rested type 1 fibres, and up to 200 mumol lactate (g dry weight)-1 had accumulated. 3. Recovery from fatigue was studied in fibres where force had fallen to 0.6 P0 (both fibre types) and 0.2 P0 (type 1 only). After 1 h of recovery ATP had in all cases returned to the level measured in rested fibres. In fibres fatigued to 0.6 P0, force almost returned to its original value. However, in type 1 fibres fatigued to 0.2 P0, it returned to only 0.3 P0. After 1 h of recovery the PCr/Cr ratio in type 1 fibres was lower (probability, P less than 0.05) than in control fibres, whereas in type 3 fibres it was not significantly different from controls. 4. The relationship between peak force and stimulus frequency, which had a sigmoid shape in fully rested fibres, was drastically changed by fatiguing stimulation. Immediately after fatiguing stimulation of type 1 fibres, force hardly increased with stimulus frequency, corresponding to the observation that calcium efflux from the sarcoplasmic reticulum was decreased at high stimulus frequencies. The force-frequency relationship of type 3 fibres was the same before and after intermittent stimulation.

We determined the physiological effects of exercise training on exercise capacity and quadriceps muscle function in patients with idiopathic pulmonary arterial hypertension (iPAH). In total, 19 clinically stable iPAH patients (New York Heart Association II-III) underwent a supervised exercise training programme for the duration of 12 weeks. Maximal capacity, endurance capacity and quadriceps function were assessed at baseline and after 12 weeks. In 12 patients, serial quadriceps muscle biopsies were obtained. 6-min walk distance and peak exercise capacity did not change after training. However, endurance capacity improved significantly after training, demonstrated by a shift of the anaerobic threshold to a higher workload (from 32±5 to 46±6 W; p=0.003) together with an increase in exercise endurance time (p

Isometric force production and ATPase activity were determined simultaneously in single human skeletal muscle fibers (n = 97) from five healthy volunteers and nine patients with chronic heart failure (CHF) at 20 degrees C. The fibers were permeabilized by means of Triton X-100 (1% vol/vol). ATPase activity was determined by enzymatic coupling of ATP resynthesis to the oxidation of NADH. Calcium-activated actomyosin (AM) ATPase activity was obtained by subtracting the activity measured in relaxing (pCa = 9) solutions from that obtained in maximally activating (pCa = 4.4) solutions. Fiber type was determined on the basis of myosin heavy chain isoform composition by polyacrylamide SDS gel electrophoresis. AM ATPase activity per liter cell volume (+/-SE) in the control and patient group, respectively, amounted to 134 +/- 24 and 77 +/- 9 microM/s in type I fibers (n = 11 and 16), 248 +/- 17 and 188 +/- 13 microM/s in type IIA fibers (n = 14 and 32), 291 +/- 29 and 126 +/- 21 microM/s in type IIA/X fibers (n = 3 and 5), and 325 +/- 32 and 205 +/- 21 microM/s in type IIX fibers (n = 7 and 9). The maximal isometric force per cross-sectional area amounted to 64 +/- 7 and 43 +/- 5 kN/m(2) in type I fibers, 86 +/- 11 and 58 +/- 4 kN/m(2) in type IIA fibers, 85 +/- 6 and 42 +/- 9 kN/m(2) in type IIA/X fibers, and 90 +/- 5 and 59 +/- 5 kN/m(2) in type IIX fibers in the control and patient group, respectively. These results indicate that, in CHF patients, significant reductions occur in isometric force and AM ATPase activity but that tension cost for each fiber type remains the same. This suggests that, in skeletal muscle from CHF patients, a decline in density of contractile proteins takes place and/or a reduction in the rate of cross-bridge attachment of approximately 30%, which exacerbates skeletal muscle weakness due to muscle atrophy.

The aim of the present study is to test whether mechanical strain uniquely regulates muscle fibre atrophy/hypertrophy and adaptation of the number of sarcomeres in series within mature muscle fibres in vitro. Mature single muscle fibres from Xenopus laevis illiofibularis muscle were cultured (4 - 97 days) while kept at negative strain (∼20% below passive slack length, 'short fibres') or at positive strain (∼5% over passive slack length, 'long fibres'). Before and after culture the number of sarcomeres in series was determined using laser diffraction. During culture, twitch and tetanic force characteristics were measured every day. Survival time of long fibres was substantially less than that of short fibres. Of the long fibres 40% died or became inexcitable within 1 week, whereas this did not occur for short fibres. During culture, twitch and tetanic force of all short fibres increased substantially. Regression analysis showed that the post-culture number of sarcomeres in series was not significantly changed compared to the number before culture. It is concluded that culture at negative strain does not result in atrophy or a reduction of the number of sarcomeres in series, even after 97 days. For the long fibres we did not detect any hypertrophy as tetanic force remained stable or decreased slowly, while twitch force varied. Regression analysis of the change of the number of sarcomeres in series as a function of the culture time showed a positive slope (P = 0.054). Two out of four long fibres that were cultured for at least 2 weeks showed an increase in the number of sarcomeres of 4 - 5%. Compared with in vivo adaptation to mechanical stimuli this is much less than would be expected. The data suggest that strain may not be the only factor that regulates hypertrophy and the number of sarcomeres in series. © 2004 Kluwer Academic Publishers.

In this study alterations are characterized which occur, in myocardial force development morphological appearance and protein composition, during the development of cardiac hypertrophy and heart failure in monocrotaline (MCT) treated rats. The transition from cardiac hypertrophy to heart failure was studied by comparing the results from control (CON) and two MCT groups (40 and 44 mg/kg body weight). The three experimental groups consisted of at least five animals each. Parameters studied were: body weight (measured daily), lung/body weight ratio, right ventricular wall volume and thickness, and force development in thin right ventricular trabeculae at 27 degrees C, using different extracellular calcium concentrations and pacing frequencies. MCT injection resulted in marked right ventricular hypertrophy and heart failure as evidenced by an up to 2-fold increase in lung/body weight ratio and a 1.7-fold increase in wall volume. The MCT groups showed a negative force-frequency relation and maximum force was up to 2-fold less than in the CON group. Protein analysis by means of one- and two-dimensional gel electrophoresis revealed a marked (7-fold) up-regulation of the slow myosin heavy chain isoform as well as a 4.5-fold increase in the content of the cytoskeletal protein desmin, whereas the mitochondrial protein ATP-synthase content was reduced. Hence MCT-induced cardiac hypertrophy and heart failure result in altered cellular calcium handling, depression of maximum force output, an increase in the economy of myocardial contraction and changes in cytoskeletal structure and energy supply.

Myocardial efficiency of pulmonary hypertensive (PH) patients and isolated right ventricular papillary muscles from PH rats can be severely reduced. We aimed to determine the causes of the efficiency reduction in isolated papillary muscles of monocrotaline-injected PH rats (MCT, 60mg/kg; 8 control and 16 MCT male Wistar rats). After 3 weeks PH was confirmed by echocardiography and right ventricular papillary muscles were isolated. Work and suprabasal oxygen consumption were determined using the work loop technique: 4 min 5 Hz sinusoidal length changes at 92.5% of optimum length (L0), amplitude 0.15 L0 in 1.5 mM Ca2+ Tyrode solution at 37°C. Morphological and enzymehistochemical characteristics of the muscle and free wall were also quantified. Cardiolipin content was determined by HPLC-MS. Passive tension (overall m±SD: 23.9±9.3 mN/mm2) and active tension at 0.5Hz (75±28 mN/mm2 myocyte) were similar in control and MCT muscles at L0. Net efficiency of control muscles was 15.5±4.9 % and correlated with cross-sectional area of myocytes (273±88 μm2) in the muscle (r=0.84, P=0.017), indicating that larger myocytes are more efficient. However, net efficiency of MCT muscles was lower (9.4±7.4%, P=0.027) and did not correlate with myocyte cross-sectional area (448±88μm2). The stimulus phase for maximum work was 40±12° in control and differed (P=0.019) from 27±9° in MCT muscles, indicating slower force development in MCT muscles. Power output per loop tended to be lower in MCT muscles (1.24±0.56 versus 0.83±0.75 μJ/mm3 myocyte, P=0.16). Work loops after crossbridge inhibition by blebbistatin (10μM) were -0.38±0.22 μJ/mm3, indicating similar viscoelastic properties of control and MCT muscles. The stimulus phase for maximum work correlated with work (r=0.72, P=0.002) and efficiency (r=0.65, P=0.006) in MCT muscles, but not with myofibrillar CaATPase activity. Oxygen consumption during stimulation after blebbistatin correlated negatively with efficiency (r=-0.60, P=0.006), indicating increased oxygen consumption for non-contractile reactions in MCT muscles. Oligomycin-resistant MgATPase activity increased (P=0.004) whereas cardiolipin 72:8 decreased (P=0.023) in right-sided myocardium of MCT, indicating changes of the mitochondrial inner membrane. Monoamine oxidase A activity (P=0.004) and glucose-6-phosphate dehydrogenase activity (P=0.0004) in myocytes increased, indicating oxidative stress and increased oxygen consumption other than oxidative phosphorylation. These results demonstrate that metabolic rather than sarcomeric changes cause reduced myocardial efficiency in experimental pulmonary hypertension.

Investigation of the mechanisms of muscle adaptation requires independent control of the regulating factors. The aim of the present study was to develop a serum-free medium to culture mature single muscle fibres of Xenopus laevis. As an example, we used the culture system to study adaptation of twitch and tetanic force characteristics, number of sarcomeres in series and fibre cross-section. Fibres dissected from m. iliofibularis (n = 10) were kept in culture at a fibre mean sarcomere length of 2.3 microm in a culture medium without serum. Twitch and tetanic tension were determined daily. Before and after culture the number of sarcomeres was determined by laser diffraction and fibre cross-sectional area (CSA) was determined by microscopy. For five fibres twitch tension increased during culture and tetanic tension was stable for periods varying from 8 to 14 days ('stable fibres'), after which fibres were removed from culture for analysis. Fibre CSA and the number of sarcomeres in series remained constant during culture. Five other fibres showed a substantial reduction in twitch and tetanic tension within the first five days of culture ('unstable fibres'). After 7-9 days of culture, three of these fibres died. For two of the unstable fibres, after the substantial force reduction, twitch and tetanic tension increased again. Finally at day 14 and 18 of culture, respectively, the tensions attained values higher than their original values. For stable fibres, twitch contraction time, twitch half-relaxation time and tetanus 10%-relaxation time increased during culture. For unstable fibres these parameters fluctuated. For all fibres the stimulus threshold fluctuated during the first two days, and then remained constant, even for the fibres that were cultured for at least two weeks. It is concluded that the present culture system for mature muscle fibres allows long-term studies within a well-defined medium. Unfortunately, initial tetanic and twitch force are poor predictors of the long-term behaviour of the fibres.

We have investigated the relationship between cross-sectional area (CSA) and maximum rate of oxygen consumption (VO2max, in nmol .mm-3 .s-1) of heart and skeletal muscle cells from different species. VO2max and CSA were determined for single muscle fibres of Xenopus laevis at 20°C and for cardiomyocytes in thin trabeculae dissected from the right ventricle of rats at 38°C. Succinate dehydrogenase activity was determined using a quantitative histochemical method to estimate VO2max in mammalian skeletal muscle fibres. Literature values of volume density of mitochondria were used to estimate VO2max in some mammalian cardiomyocytes. We found that an inverse relationship exists between VO2max (range 1.5 to 0.024 nmol . mm-3 . s-1) and cross-sectional area (0.0002 to 0.018 mm2, respectively): VO2max = constant/CSA, where the value of the constant equals 0.39±0.18 pmol . mm-1 .s-1 (mean ± S.D., n = 14). Such a relationship is predicted by a simple Hill-type model for oxygen diffusion in cilindrical cells, if it is assumed that muscle cells are evolved so that anoxic cores in muscle cells are prevented. This indicates that the product of endurance of muscle cells (which is proportional to VO2max) and force production (which is proportional to cross-sectional area) is limited by oxygen diffusion, and that adaptation of heart and skeletal muscle cells to increased workload is limited by the interstitial oxygen tension.

We studied the relation between force normalized by dry mass per unit length and the myosin fraction of muscle dry mass. The two tibialis anterior muscles were dissected from 12 frogs (Rana temporaria). Then, from one muscle, two single fast-twitch fibres were isolated. Each fibre was mounted isometrically in Ringer's solution, and electrically stimulated using a standardized protocol. Peak force production, normalized by the fibre's dry mass per unit length, varied by a factor of 1.4. Little variation in normalized force was measured between fibres from the same animal, whereas between animals a significant difference was found (P

We studied the effect of thyroid hormone (3,5,3'-triiodo-L-thyronine, T3) on the expression of sarcoplasmic reticulum (SR) fast- and slow-type Ca(2+)-ATPase isoforms, SERCA1 and SERCA2a, respectively, and total SR Ca(2+)-ATPase activity in rat skeletal muscle. Cross sections and homogenates of soleus and extensor digitorum longus muscles from hypo-, eu-, and hyperthyroid rats were examined, and expression of Ca(2+)-ATPase isoforms in individual fibers was compared with expression of fast (MHC II) and slow (MHC I) myosin heavy chain isoforms. In both muscles, T3 induced a coordinated and full conversion to a fast-twitch phenotype in one-half of the fibers that were slow twitch in the absence of T3. The conversion was partial in the other one-half of the fibers, giving rise to a mixed phenotype. The stimulation by T3 of total SERCA expression in all fibers was reflected by increased SR Ca(2+)-ATPase activity. The time course of the T3-induced changes of SERCA isoform expression was examined 1-14 days after the start of daily T3 treatment of euthyroid rats. SERCA1 expression was stimulated by T3 at a pretranslational level in all fibers. SERCA2a mRNA expression was transiently stimulated and disappeared in a subset of fibers. In these fibers SR Ca(2+)-ATPase activity was high because of high SERCA1 protein levels. These data suggest that the ultimate downregulation of SERCA2a expression, which is always associated with high SR Ca(2+)-ATPase activities, occurs at a pretranslational level.

Mature, high-oxidative, skeletal muscle fibres of Xenopus laevis were kept in culture in L-(Leibovitz's)-15 medium supplemented with creatine and antibiotics and some other additions. Single fibres were mounted at a fixed sarcomere length in a flow-through culture chamber which accommodates stimulus electrodes and a force transducer. Twitch characteristics were determined daily. Depending on culture conditions, fibres remained excitable electrically for up to two weeks at 20 degrees C when foetal calf serum and/or phosphate were added to the culture medium. During the second week, fibres lost phosphocreatine and ATP, but relatively small changes (if any) in total creatine, glycogen and protein contents, fibre volume and dry weight occurred. Succinate dehydrogenase activity decreased after 9 days-when ATP was reduced already. Fibres which were inexcitable electrically contracted normally when exposed to caffeine, indicating that excitation-contraction coupling failed and that the contractile apparatus was still functional.

This report describes the development of a histochemical method for the demonstration of sarcoplasmic reticulum Ca-ATPase activity in cross-sections of skeletal muscle. The demonstration of sarcoplasmic reticulum Ca-ATPase activity is complicated by the fact that capturing reagents for phosphate inhibit the enzyme. We present a minimal model for heavy-metal-phosphate precipitation reactions which gives a theoretical description of the effect of enzyme inhibition on the rate of phosphate precipitation in the section. The model indicates that the choice of capturing reagent is crucial: whether or not ATPase activity can be demonstrated depends mainly on the inhibition constant and the solubility product of the phosphate salt of the capturing reagent (but also on a fairly large number of other factors). All lanthanides tested can be used to demonstrate sarcoplasmic reticulum Ca-ATPase activity, but dysprosium results in the highest staining intensity. This suggests that dysprosium inhibits sarcoplasmic reticulum Ca-ATPase to a lesser degree than the other lanthanides and/or the solubility product of its phosphate salt is smaller. As an example, the method is used to investigate the effect of thyroid hormone on sarcoplasmic reticulum Ca-ATPase activity in individual fibres of the rat soleus muscle.

This report describes changes of the rate of ATP hydrolysis in single, intact muscle fibres during the development of fatigue induced by intermittent tetanic stimulation. High (type 3) and low (type 1) oxidative muscle fibres dissected from the iliofibularis muscle of Xenopus laevis were studied at 20 degrees C. The rate of ATP hydrolysis was calculated during different time intervals from changes in the content of nucleotides, creatine compounds and lactate, as well as lactate efflux and oxygen uptake. During the first phase of intermittent stimulation, phosphocreatine is fully reduced while the rate of oxygen consumption increases to its maximum, the lactate content increases to a maximum level, and a small amount of IMP is formed; the rate of ATP hydrolysis in type 3 fibres is constant while force decreases, whereas the rate decreases approximately in proportion to force in type 1 fibres. After the first phase, the rate of ATP hydrolysis in type 3 fibres decreases slightly and the fibres reach a steady metabolic state in which the rates of ATP formation and hydrolysis are equal; in type 1 fibres a drastic change of the rate of ATP hydrolysis occurs and a steady metabolic state is not reached. On the basis of the time courses of the metabolic changes, it is concluded that the rate of ATP hydrolysis in type 3 fibres is reduced by acidification and/or a reduced calcium efflux from the sarcoplasmic reticulum, whereas in type 1 fibres inorganic phosphate and/or acidification inhibit the rate initially and ADP is a likely candidate to explain the drastic fall of the rate of ATP hydrolysis during late phases of fatiguing stimulation.

A fairly simple method for calibrating microdensitometric histochemical assays is described. The method is based on paired biochemical and histochemical assays on single freeze-dried skeletal muscle fibers which differ widely in their properties. As an example, the method is applied to investigate the validity of the periodic acid-Schiff (PAS) reaction for the microdensitometric estimation of glycogen content. Some problems that may interfere with the calibration are discussed.

Sepsis is often accompanied by myocardial depression; one of the possible mechanisms includes mitochondrial injury. We hypothesized that opening of the mitochondrial permeability transition pore (mPTP) may occur during sepsis-induced myocardial depression. We investigated the opening of the mPTP in septic hearts by measuring cytochrome C release into the cytosol.

This report describes how the resistance to fatigue of a muscle fibre relates to the fibre's most important ATP-producing and ATP-consuming reactions. Twelve intact single muscle fibres were dissected from lumbrical muscles of Xenopus laevis. Their resistance to fatigue induced by repeated tetanic stimulation was determined, as well as their succinate dehydrogenase activity and calcium-stimulated myofibrillar ATPase activity. The enzyme activities were determined by means of quantitative histochemistry. It was found that resistance to fatigue correlates with succinate dehydrogenase activity (r = 0.83) and with myofibrillar ATPase activity (r = -0.74). The highest correlation was found between resistance to fatigue and the ratio of succinate dehydrogenase to myofibrillar ATPase activity (r = 0.93). It is concluded that muscular fatigue is closely related to cellular energetics.

Little is known about the energetics of the failing heart. In man it is well known that energy metabolism is affected in chronic heart failure (Ingwall & Weiss, 2004). Genetically modified mice are useful in the study of heart disease. A persistent headache has been the lack of basic energetic data. In this issue of The Journal of PhysiologyWiden & Barclay (2006) give us both a method and the first data. For the first time, the basic energetic characteristics of mouse heart muscle activation and contraction have been measured in papillary muscle. Mice can be obtained relatively easily and the mouse genome has been sequenced. The proportion of mouse genes without a human homologue is probably less than 1% (Mouse Genome Sequencing Consortium, 2002). Numerous mouse models for studying heart disease exist already and the number is increasing (Wang et al. 2004). Gene products are processed in cells resulting in many more proteins than genes and a staggering number of possible interactions between the different proteins exist. One important question is then: How does one relate gene function to the final contractile characteristics of cardiomyocytes? Muscles produce mechanical work and heat in different amounts and proportions, depending on the type of muscle and the load (Hill, 1965; Woledge et al. 1985). ATP required for ion pumps and cardiomyocyte shortening is buffered by the Lohmann reaction in the myoplasm. This keeps the ATP concentration constant while the phosphocreatine concentration decreases when the muscle is activated. Net splitting of phosphocreatine releases 34 kJ mol−1 (Woledge et al. 1985). This energy is partly converted into mechanical work during systole when the phosphocreatine concentration decreases and the rest is liberated as heat. A metabolic steady state can only be maintained when creatine is rephosphorylated during one heart cycle. The energy for this is produced by oxidation of fat or carbohydrate, 439 or 473 kJ (mol O2)−1, respectively. Depending on the efficiency of the oxidation (the ∼P/O2 ratio), part of the energy is used to rephosphorylate creatine, and the remainder is liberated as heat. Heat production increases the temperature of the heart muscle preparation, which can be measured using a thermopile. The myothermic technique has a higher time resolution than oxygen consumption or 31P-NMR which are too slow to determine energy fluxes during a single contraction. The interpretation of heat production data requires that the biochemical reaction producing it is known. This is complicated in heart muscle because contraction-related processes, i.e. heat production due to ion pumps and cross-bridge cycling, and oxidative phosphorylation, usually occur simultaneously. Another challenge is that mouse hearts are small (about 0.1–0.2 g) and operate at high metabolic rates (Gibbs & Loiselle, 2001). The risk that the preparation becomes anoxic is considerable. This is a problem because heat production by partly anoxic preparations cannot be interpreted reliably, and because reoxygenation can damage anoxic cardiomyocytes. The maximum rate of oxygen consumption of mouse heart muscle is not known, but can be estimated on the basis of volume density of mitochondria and the rate of oxygen consumption of rat myocardial trabeculae, 0.58 nmol mm−3 s−1 at the maximum heart rate (van der Laarse et al. 2005), 600 beats min−1, which is the resting rate in mice. Mouse cardiomyocytes contain 38% (v/v) mitochondria and rat cardiomyocytes contain 32% (Barth et al. 1992). Assuming the maximum rate of oxygen consumption is proportional to volume density of mitochondria, the maximum rate of oxygen consumption of mouse trabeculae is about 0.7 nmol mm−3 s−1. At this rate of oxygen consumption, the mouse heart becomes anoxic a few seconds after perfusion stops and superfused preparations, e.g. papillary muscles or trabeculae at experimental PO2 of 500 mmHg, must have diameters of less than 160 µm to prevent an anoxic core. Widen & Barclay (2006) solved these problems and determined heat produced by calcium cycling and heat produced by cross-bridge cycling in papillary muscles of Swiss mice. Contraction-related heat was determined during the first three contractions of a series, making use of the relatively slow onset of recovery metabolism at 27°C. Hypoxia was prevented using stimulus periods of 20 s, sufficiently short not to deplete oxygen stored in the muscle, and contraction and activation-related heat were separated by partial inhibition of cross-bridges using butanedione monoxime (Alpert et al. 1989). The results indicate that about one Ca2+ cycles per three cross-bridge cycles, and that the number of cross-bridge cycles per cardiac twitch is half the number of available cross-bridges. How these numbers vary with genotype and intervention remains to be determined.